Referral Form

Please complete the form below to refer a patient to Ambulatory Veterinary Surgery.

Ambulatory Veterinary Surgery

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Is this an URGENT referral?

Yes
No

Client Name *

First

Last

Co-Owner's Name

First

Last

Client Preferred Phone Number *

Does the client have special needs?

Yes
No

Client Email

Patient Name *

Species

Breed *

Color *

Gender

F
FS
M
MN

Date of Birth *

Is this patient a Caution?

Yes
No

REFERRING VETERINARIAN DATA

Name of Doctor *

First

Last

Hospital *

Veterinarian Email *

Regular Client at Your Hospital?

Yes
No

Referral to Department *

Surgery
Oncology
TPLO

Significant/Previous Medical History (Including Allergies) *

Current Medical Concern (Please indicate/describe chief complaint, onset, progression, treatment, response) *

Tentative Diagnosis Given to Client *

Current Medications *

VACCINE HISTORY:

Current on Vaccinations?

Yes
No

MEDICAL RECORDS:

Please be sure to include all medical notes pertinent to the concern. If the concern has been ongoing for 6 months, please send everything for 6 months. If the concern has been ongoing for 6 years, please send everything for 6 years.

COMPLETED DIAGNOSTIC REPORTS:

If you have completed any of the following pertinent lab work or other test results, please attach original copies.

Diagnostic Reports

CBC
Chemistry
Urinalysis
Thyroid Testing
Pathology/Cytology
HW/Lyme/Ehrlichia
ECG
Blood Pressure
Surgery Reports Related to Concern
Image Reports
Radiographs
Ultrasound Studies
CT
MRI
Other

Upload Medical Records

Click or drag files to this area to upload. You can upload up to 10 files.

We proudly serve the pets of Baltimore, Maryland and the surrounding area.

Thank you for trusting Ambulatory Veterinary Surgery with your patients. We look forward to providing them with the most comfortable surgical experience possible.

Referral Form

Ambulatory Veterinary Surgery

We proudly serve the pets of Baltimore, Maryland and the surrounding area.

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