small animal referral form may-updated - massey university
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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)
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_____________________________________________________________________________________ Current drug therapy and/or response to previous medications:
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_____________________________________________________________________________________ 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 [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