Referral Form

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TUVMTH LARGE ANIMAL PATIENT REFERRAL FORM
Please type and Fax this form to: 334-724-4305
Or, E-mail (and include labs and/or radiographs as PDF attachments) the form to: [email protected]
*Please call us at 334-727-8461 to confirm the referral and help us address any questions in person*
Services Requested (Please mark with an “X” to the left of the service requested):
Internal medicine
Emergency
Surgery
Other:
Referring Veterinarian Information
Date:
Patient name:
Doctor name::
Hospital name:
Phone #
Client’s name:
Client’s Phone #
Species:
Fax #
Age:
Email:
Markings:
How would you like to be contacted? (Please mark with an “X” to the left of the contact method requested)
E-mail
Phone
Fax
Mail
Address:
Patient History & Husbandry
Summary of available Diagnostics (Please attach a copy of completed Tests, Labs and Medical Records)
Mark “X” if sending x-rays or other diagnostic images with client
Treatments / Medications
(Please include any vaccination history)
Additional Comments
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