Referral Form

The following form may be completed by veterinarians only who are referring clients to the Auburn University Small Animal Hospital.  

DO NOT USE THIS FORM IF THIS IS AN EMERGENCY!
For emergencies, call 844-4690 and choose option 3 from the menu. 

Please complete all fields below and press the SEND button. You will receive an on-screen recap of your submission as well as an email confirmation.  Please verify that you have not left off any information for fields with an asterisk, as these are required. 

A valid e-mail address is required to use this form. Please enter the e-mail address of the referring veterinarian carefully.  

Required fields are indicated by *.

***NOTICE***

You will receive a printable confirmation (via email) for your records. If you do not receive an email confirmation within the hour, first check your "spam" folder.  You will not receive email confirmation if your email address was entered incorrectly, however we may still have received your referral. If you are unsure, please contact us at 334-844-4690 (option 3).

After submitting this referral, please have your client call us at 334-844-4690 to schedule the appointment. 

From (the name of the person completing this form if not the rDVM) *
Referring veterinarian's email: (Please make sure that the email is entered correctly, as confirmations will be sent to the address entered here).	Confirmations will be sent to the email address provided above.
Subject:	Small Animal Patient Referral
Referring Veterinarian's First Name *	Only one veterinarian's name please
Referring Veterinarian's Last Name *
Service Referring To *	Cardiology Dermatology Internal Medicine General Surgery Neurology Oncology (Medical) Oncology (Surgical) Oncology (Radiation) 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 *	(xxx)xxx-xxxx
Client Business Phone	(xxx)xxx-xxxx
Your Clinic Name
Your Clinic Address
Your Clinic Address 2
Your Clinic City
Your Clinic State
Your Clinic Zip Code
Your Clinic Phone *	(xxx)xxx-xxxx
Your Clinic FAX	(xxx)xxx-xxxx
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	NegativePositiveUnknown
Is the patient on heartworm preventative?	YesNoUnknown
FELV Status *	Not ApplicableNegativePositiveUnknown
FIV Status *	Not ApplicableNegative PositiveUnknown
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 (mm/dd/yyyy)
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 in the following box. *	(This will serve as your signature for the purpose of this form)
Date and Time Submitted:	6/15/2013 2:53 pm
You must use the "Send" button below to submit this form. If all "required" fields were not entered, you will be taken back to the form to complete the required information. A message at the top of the form will tell you what was omitted. If it was comple
Verify Your Humanity

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The faculty of the Small Animal Hospital recognize that the basis for proper medical referral care and communication begins with the information you provide.

Appointments are necessary, but every attempt will be made to make your client feel welcome. It will help your client to know that the Small Animal Hospital does not routinely bill. Payment by cash, check, Visa, or Mastercard is accepted. Care Credit is available if requested by the owner.  A deposit of the median point between the high and low estimate is due on admission and the balance is due on discharge.