Referral Form

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Referral Type:

Emergency Referral

Specialty Referral

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Referring Veterinary Information

Practice Name:

Referring Veterinarian:

Practice Phone Number:

Practice Fax Number:

Please contact in case of dire change in condition or prognosis:

Contact Number:

Client Information

Name:*

First Last

Address:

Street Address Address Line 2 City State ZIP Code

Telephone:

Patient Information

Name:

Species:

Breed:

Age:

Sex:

Weight:

Referral Information

Presenting Complaint:

Duration of Complaint:

Relevant History and Treatment:

Provisional Diagnosis:

Provisional Prognosis:

Please include all recent blood work, lab findings, x-rays and current medications to minimize repeat testing and lab work. X-rays may be e-mailed to reception@lancasterpetemergency.com or sent with your client.

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Name

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