On-Line 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! Please complete all fields below and press the SEND button. Wait for a confirmation page after submitting your request. If you do not receive the confirmation page, your form was not properly processed and should be resubmitted.  A valid e-mail address is required to use this form. Please enter your e-mail address carefully.   Required field are indicated by *.   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 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 on discharge. From: (your email address here) Subject: How do you wish to handle this referral? * Contact your office first.Contact client at home first.Contact client at work first. Your office will be contacted if client cannot be. Service Referring To: DermatologyInternal MedicineGeneral SurgeryNeurologyOncologyOphthalmologyOrthopedic Surgery Has this patient been to Auburn before? Yes No Client Name: * Client Address: Client Address 2: Client City: Client State: Client Zip: Client Home Phone: * Client Business Phone: Referring Veterinarian: * Hospital Name: Hospital Email Address: Hospital Address: Hospital Address 2: Hospital City: Hospital State: Hospital Zip Code: Hospital Phone: * Hospital FAX: Patient Name: Species: DogCatFerretOther If other please specify: Patient Breed: Patient's Age: years - months (3-10) Patient's Sex: MaleMale (neutered)FemaleFemale (neutered) Patient's Weight: (in pounds) Please check any vaccine that has been given to the patient. If a vaccine has not been given, please leave the field blank. Rabies Canine Distemper/Parvo Bordatella Feline Respiratory Virus Feline Leukemia Please give the dates that the vaccines above were last administered. Please list each vaccine and it's date separately. Current Heartworm Status: NegativePositiveUnknown Is the patient on heartworm preventative? YesNoUnknown FELV Status: Not ApplicableNegativePositiveUnknown FIV Status: Not ApplicableNegativePositiveUnknown Date of last examination at your office: Reason for Referral: History: Treatment: I plan to forward copies of the following patient information at the time of referral (Please check all that apply) None Patient Medical Record CBC Biochem Profile Urinalysis Biopsy/Cytology Report Radiographs Serology Endocrinology Microbiology 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 purposes of this form)