small animal referral form may-updated - massey university

Private Bag 11 222 Ph: (06) 350 5329 Palmerston North 4442 Fax: (06) 350 5616 Small Animal Referral Form Office use only: Date of Appointment: ___________________________________ Veterinary Signature: ______________________________________ Confirmation: Initials: ___________ Approximate Cost: ________________________________________ Copy to Service Dog Co-ordinator Date:___________ Veterinarian: _____________ Practice Name: ____________ Medicine Orthopaedics Neuro/Spinal Behaviour Cardiology Soft Tissue Surgery Radiology 2 nd Opinion Dermatology Oncology Endodontics URGENT NON URGENT Phone: ____________________ Fax: ____________________ Email: ________________________ Preferred method of contact: □ Phone □ Fax □ Email Please send me a copy of: Referral Letter Discharge Notes by Fax Email When can we reach you in the next 24 hours? _____________________________________________ Client/Handler Name: ____________________________ Animal Name:_______________________ Client Address: _________________________________ Species: ___________________________ _______________________________________________ Breed: ____________________________ Client Phone/Mobile: _____________________________ Colour: ________________ Sex: ____ Client Email: ____________________________________ Age: ________ Neutered: Yes No If service dog tick one of following: Police Dog Guide Dog Other: ________________ Microchip#: ____________________________________ Medallion #: ______________________ Brief History: (attach medical record/case summary) (For service dogs) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Current drug therapy and/or response to previous medications: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please indicate diagnostic tests already performed and attach results: CBC Chemistry Profile Urinalysis Cytology Biopsy Thoracic Radiographs Date: _______________________ Ultrasound Date: _______________ Other Tests: ________________________________________________________________________ Check List Fax medical record/case summary Fax laboratory results Send all radiographs with owner Quotation required Possible referral (please discuss first) Definite referral (please make an appointment Replacement forms can be downloaded from our website: http://vethospital.massey.ac. Contact us at [email protected] Hospital Director Janet Molyneux MBA, VN Anaesthesia Vicki Walsh BVSc MACVSc Mike Gieseg BVSc, PhD Hiroki Sano BVSc Behaviour Kevin Stafford MVB MSc PhD MAVSc Registered Specialist Rachael Stratton BVSc Community Practice Angus Fechney BVSc Alison Harland BVSc Kevanne McGlade BVSc Helen Orbell BSc(Hons) BVSc(Hons) MACVSc(Hons) Diagnostic Imaging Eli Cohen BS DVM Small Animal Medicine Els Acke VetSurg, PhD, DipECVIM- CA, CertSAM Nick Cave BVSc MVSc MACVSc DipACVN Kate Hill BVSc(Hons) DipACVIM Registered Specialist Sarah Hill BVSc Steve Crow BS, DVM, DipACVIM(SAIM, ONC) Ewan Wolff BSc, DVM, PhD Small Animal Surgery Richard Kuipers von Lande BVSC CertVR CertSAS MACVSc Andrew Worth BVSc MACVSc PGDipVCS FACVSc Registered Specialist Jonathan Bray MVSc, MACVSc, CertSAS, MRCVS, DiplECVS RCVS/Euro Specialist Kat Crosse MA VetMB MANZCVS MRCVS

Upload: others

Post on 05-Jan-2022

1 views

Category:

Documents

0 download

Report

Download

Embed Size (px):

TRANSCRIPT

Private Bag 11 222 Ph: (06) 350 5329 Palmerston North 4442 Fax: (06) 350 5616

Small Animal Referral Form

Office use only: Date of Appointment: ___________________________________ Veterinary Signature: ______________________________________ Confirmation: ¨ Initials: ___________ Approximate Cost: ________________________________________ Copy to Service Dog Co-ordinator ¨

Date:___________ Veterinarian: _____________ Practice Name: ____________

Medicine Orthopaedics Neuro/Spinal Behaviour Cardiology Soft Tissue Surgery Radiology 2nd Opinion Dermatology Oncology Endodontics

URGENT NON URGENT

Phone: ____________________ Fax: ____________________ Email: ________________________ Preferred method of contact: □ Phone □ Fax □ Email Please send me a copy of: ¨ Referral Letter ¨ Discharge Notes by ¨ Fax ¨ Email

When can we reach you in the next 24 hours? _____________________________________________

Client/Handler Name: ____________________________ Animal Name: _______________________

Client Address: _________________________________ Species: ___________________________

_______________________________________________ Breed: ____________________________

Client Phone/Mobile: _____________________________ Colour: ________________ Sex: ____

Client Email: ____________________________________ Age: ________ Neutered: ¨ Yes ¨ No If service dog tick one of following: ¨ Police Dog ¨ Guide Dog ¨ Other: ________________

Microchip#: ____________________________________ Medallion #: ______________________

Brief History: (attach medical record/case summary) (For service dogs)

_____________________________________________________________________________________

_____________________________________________________________________________________ Current drug therapy and/or response to previous medications:

_____________________________________________________________________________________

_____________________________________________________________________________________ Please indicate diagnostic tests already performed and Uattach results: ¨ CBC ¨ Chemistry Profile ¨ Urinalysis ¨ Cytology ¨ Biopsy ¨ Thoracic Radiographs Date: _______________________ ¨ Ultrasound Date: _______________ ¨ Other Tests: ________________________________________________________________________ Check List ¨ Fax medical record/case summary ¨ Fax laboratory results ¨ Send all radiographs with owner ¨ Quotation required ¨ Possible referral (please discuss first) ¨ Definite referral (please make an appointment

Replacement forms can be downloaded from our website: http://vethospital.massey.ac.

Hospital Director Janet Molyneux MBA, VN

Anaesthesia Vicki Walsh BVSc MACVSc

Mike Gieseg BVSc, PhD

Hiroki Sano BVSc

Behaviour Kevin Stafford MVB MSc PhD MAVSc Registered Specialist

Rachael Stratton BVSc

Community Practice Angus Fechney BVSc

Alison Harland BVSc

Kevanne McGlade BVSc

Helen Orbell BSc(Hons) BVSc(Hons) MACVSc(Hons)

Diagnostic Imaging Eli Cohen BS DVM