Companion Animal Referral Form InstructionsThe following form is to be used by veterinarians who are referring a non-emergent case to the Auburn University Small Animal Hospital. For emergency referrals to the Auburn University Small Animal Hospital, please call 334- 844- 4690 and press 3. Do not use this form if this is a referral for Auburn University Veterinary Specialists in Gulf Shores. Please call 334- 844- 4690, press 3 and specify type of referral. Once you have submitted this referral, please allow a minimum of two hours for data entry before having your client call us at 334-844-4690 to schedule the appointment. Supporting medical history and patient records are required in order to ensure that our clinicians, technical staff, and DVM students have the most up-to-date information regarding the referral. The faculty of the Bailey Small Animal Teaching Hospital emphasize that the basis for strong communication and a team approach to the patient’s care begins with the information you provide. Please send supplemental patient records and lab work by email (firstname.lastname@example.org) or fax (334-844-6034) to the attention of: Casey Milton, referral coordinator. Digital imaging can be emailed to the email address above or sent directly to our server via dicom. Please include the patient/owner name as well as the service your patient is being referred to. If you need additional details about sending imaging, please contact Casey Milton at 334-844-5230. This phone line is for the service of referring veterinarians and their staff only. Client InformationClient Name* First Last Client Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client EmailThis e-mail will be used for follow-up and correspondence pre/post appointment.Client Home/Cell Phone*Client Business PhoneHas this client had a pet seen at Auburn University CVM before?*YesNoNot SureHas this patient been seen at Auburn before?*YesNoNot SureAppointment Scheduling*I have asked client to call to schedule appointment.Please call client to schedule appointment.Patient InformationPatient Name*Species*DogCatFerretOtherIf other, please specify*Patient BreedPatient ColorPatient WeightPlease enter weight in lb or kgPatient's Age (years-months )*years - months (3-10)Patient's Sex*MaleMale (neutered)FemaleFemale (spayed)Rabies vaccinationsAll patients must be rabies vaccinated in accordance with Alabama state law and Auburn University policy. If your patient will not be up to date and cannot be vaccinated, please call the referral office. Thank you.Rabies vaccinations*Please list the last two known Rabies vaccines separated by a comma. This information is required.Rabies vaccinationIf the patient has had a rabies vaccine please let us know if the rabies vaccination is a 1 year or 3 year vaccine. 1 year vaccine 3 year vaccine FELV Status*NegativePositiveUnknownNot ApplicableFIV Status*NegativePositiveUnknownNot ApplicableCurrent Heart Worm StatusNegativePositiveUnknownIs the patient on heartworm preventative?YesNoUnknownLast known Canine Distemper/Parvo Last known Bordetella vaccine Date of last examination at your office* Last known Feline Respiratory Virus Service Referring To*Please enter all that apply Avian/Exotics Cardiology Dermatology Internal Medicine Soft Tissue Surgery Neurology Oncology (Medical) Oncology (Surgical) Oncology (Radiation) Ophthalmology Orthopedics Hemodialysis / Renal Therapy Theriogenology Reason for Referral*Patient HistoryWe greatly appreciate you sending case information you have on your patient. Please do not send a copy of your complete medical record. We request instead a summary of the case including the dates that patient was seen, your findings, tests that were done, etc. as well as any medications used with the dose and patient’s response. Please send results of diagnostic testing.What is your working diagnosis?* If you don’t have one, please state that.Do you have any particular tests in mind you want us to perform?*Please enter history*TreatmentPlease enter treatment*Include medications/dosage/date startedI plan to forward copies of the following patient information or have already done so:* Summary of Patient History CBC Biochem Profile Urinalysis Biopsy/Cytology Report Radiographs Serology Endocrinology Microbiology rDVM Clinic InformationPlease enter your clinic's contact information below.Referring Veterinarian*Only one veterinarian's name please First Last Referring veterinarian's email*Please make sure that the email is entered correctly, as confirmations will be sent to the address entered here. Enter Email Confirm Email Clinic Name*Clinic Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Clinic Phone*Clinic FaxSignature and confirmationYou must use the "Submit" 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.Signature*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. Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms.