Small Animal Referral Form

(1)

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

□

^Emai

^l

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.

Contact us at vetclinic@massey.ac.nz

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