Referring Clinic / Doctor

Clinic Name *

Doctor Name *

Clinic Phone Number *

After Hours Contact Number

Do Not Call After (add time)

Email Address

Consultation Details *

Pet Owner Information

First Name *

Last Name *

Phone *

Alternate Phone

Email Address

Address *

City *

State *

Zip Code *

Patient Information

Pet Name *

Age / Date of Birth *

Species *

Breed *

Sex *

Weight (lb/kg) *

Vaccine History (list recent vaccines) *

Disposition (select one) *

Even

Caution

Emergency Information

Presenting Complaint *

Diagnosis *

Diagnostics Performed *

Findings *

Current Medications, Treatments Performed, Recent Surgery, Other. Please include the time medicine was last given or when treatments were complete. *

Recommended Diagnostics/Treatment *

Instructions for Emergency Doctor. Please include medication doses, route of administration, fluid type and rate. *

Upload any relevant documents (radiographs, blood work, etc)

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Next Steps (Please check all that apply) *

Bill us for client charges

Patient is to return to my hospital for continued care

Please keep patient for workup

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Emergency Referral Form

Referring Clinic / Doctor

Pet Owner Information

Patient Information

Emergency Information

New Patients Welcome