Client Information Form

We encourage clients to complete this form before their visit. This will ensure a minimal wait time upon arrival.

From (please list your e-mail) *	(Required)
To (referring veterinarian's e-mail)
Subject	Client Information Form
Referring Veterinarian's First Name *
Referring Veterinarian's Last Name *
Service Referring To *	Cardiology Dermatology Internal Medicine General Surgery Neurology Oncology Ophthalmology Orthopedic Surgery Hemodialysis / Renal Therapy
Has this patient been seen at Auburn before? *	Yes No
Client's First Name *
Client's Last Name *
Client Address *
Client Address 2
Client City *
Client State *
Client Zip Code *
Client E-mail: (this e-mail will be used for follow-up and correspondence pre/post appointment)
Client Home Phone *
Client Business Phone
Hospital Name
Hospital Address
Hospital Address 2
Hospital City
Hospital State
Hospital Zip Code
Hospital Phone *
Hospital FAX
Patient Name (animal name) *
Species *	Dog Cat Ferret Other
If other please specify
Patient Breed
Patient's Age (years/months ) *	years - months (3-10)
Patient's Sex *	Male Male (neutered) Female Female (neutered)
Patient's Weight *	(In pounds)
Current Heart Worm Status
Is the patient on heartworm preventative?
FELV Status *
FIV Status *
Date of last examination at your office *
Reason for Referral *
History *
Treatment *	(Include medications/dosage/date started)
I plan to forward copies of the following patient information or have already done so:	None Patient Medical Record CBC Biochem Profile Urinalysis Biopsy/Cytology Report Radiographs Serology Endocrinology Microbiology (Please check all that apply)
Last known Rabies vaccine
Last known Canine Distemper/Parvo (mm/dd/yyyy)
Last known Bordatella vaccine (mm/dd/yyyy)
Last known Feline Respiratory Virus (mm/dd/yyyy)
Last known Feline Leukemia (mm/dd/yyyy)
I am a licensed veterinarian practicing within the United States. All of the information entered in this form is accurate and trustworthy to the best of my knowledge. If this statement is true, please type your initials int he following box. *	(This will serve as your signature for the purpose of this form)
Date and Time Submitted:	6/15/2013 10:15 pm