Referring Practices | Veterinary Emergency Care

Referring Veternarian Information

Name *

Hospital *

Email *

Phone *

Client Information

Name *

Address *

Email *

Phone *

Patient Information

Name *

Age/Date of Birth *

Breed *

Color *

Gender *

Weight *

Temperment Notes *

Transfer Information

Clinical Diagnosis *

Presenting Complaint *

Findings/Diagnostics Performed *

Current Supplements and Medications *

Plan For Continued Care At Emergency *

*PLEASE NOTE: Emergency will honor a discounted exam fee for clients that are transferring from a referring hospital with a COMPLETE CARE PLAN in place. A care plan includes a completed transfer form and copies of diagnostics performed. Otherwise, our regular ER examination fee will apply.*

Referring Veternarian Information

Name *

Hospital *

Email *

Phone *

Client Information

Name *

Address *

Email *

Phone *

Patient Information

Name *

Age/Date of Birth *

Breed *

Color *

Gender *

Weight *

Temperment Notes *

Clinical Information

Differential Diagnosis *

Presenting Complaint *

History & Supporting Information (Please include copies of any lab work, radiographs, ultrasound, etc.) *

Current Supplements and Medications (Please include dose) *

Plan For Continued Care At Emergency *

*If possible, please have the veterinarian call us so they can speak with the ER Veterinarian on duty. We want to make the process as smooth as possible for both your hospital and the client.*

Referring Veternarian Information

Name *

Hospital *

Email *

Phone *

Client Information

Name *

Address *

Email *

Phone *

Patient Information

Name *

Age/Date of Birth *

Breed *

Color *

Gender *

Weight *

Temperment Notes *

Outpatient Ultrasound Procedure Information

Patient History and Supporting Information (Please send history/bloodwork/xrays) *

Working Diagnosis *

Rule Outs *

*PLEASE NOTE Client will incur additional costs if the pet requires sedation. Please prepare your client for the possibility of a physical exam and sedation fees. A physical exam will be required before we can sedate any patient. An estimate will be presented to client at time of the procedure. If you know the patient will need sedation, let us know so that time can be appropriately allotted.*

Referring Veternarian Information

Name *

Hospital *

Email *

Phone *

Client Information

Name *

Address *

Email *

Phone *

Patient Information

Name *

Age/Date of Birth *

Breed *

Color *

Gender *

Weight *

Temperment Notes *

Clinical Information

Differential Diagnosis *

Presenting Complaint *

Owner’s Goals for Recovery/Activity *

Current Supplements and Medications (Please include dose) *

Referring Veterinarians

Emergency

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Emergency

Rehabilitation