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Patient
Consult Form
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Patient
Consult Form
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Referring Veterinarian Information
Referring Veterinarian's Name
*
First
Last
Hospital Name
*
Contact Email
*
**Email address we'll use to communicate about the case, send our Surgery Day Email Confirmation and Surgery Paperwork + Invoice.
Hospital Phone
Client Information
Client Name
*
First
Last
Patient Information
Patient Name
*
Age
*
Breed
*
Sex
*
Intact Male
Intact Female
Neutered Male
Spayed Female
Weight (in kilograms)
*
If your practice records weight in pounds, please divide by 2.2 (1 kilogram = 2.2 pounds).
Chief Complaint & Relevant History
Summary of Physical Exam Findings
*
Briefly describe the relevant exam findings that support your diagnosis.
Summary of Lab Results & Diagnostic Imaging
*
Identify any notable information found on diagnostic testing. Please attach the lab results even if results are "Within Normal Limits".
Diagnosis
*
Let's discuss if unsure. Please identify the affected side (right vs. left) when relevant.
Current Medications
*
Please attach relevant radiographs & lab work results here
Click or drag files to this area to upload.
You can upload up to 6 files.
Signature
*
Clear Signature
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