Companion Animal Referral Form

Instructions

The 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.

If this is a referral for Veterinary Specialists in Gulf Shores, please use the Gulf Shores Online Referral Form or call (251) 227-8480.

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 (referral@vetmed.auburn.edu) 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 Information

Client Name(Required)

First Last

Client Address(Required)

Street Address City State ZIP Code

Client Email

This e-mail will be used for follow-up and correspondence pre/post appointment.

Client Home/Cell Phone(Required)

Has this client had a pet seen at Auburn University CVM before?(Required)

Yes

Not Sure

Has this patient been seen at Auburn before?(Required)

Yes

Not Sure

Appointment Scheduling(Required)

I have asked client to call to schedule appointment.

Please call client to schedule appointment.

Patient Information

Patient Name(Required)

Species(Required)

Dog

Cat

Ferret

Other

If other, please specify(Required)

Patient Breed

Patient Weight

Please enter weight in lb or kg

Patient's Age (years-months )(Required)

years - months (3-10)

Patient's Sex(Required)

Male

Male (neutered)

Female

Female (spayed)

Temperament(Required)

Friendly

Use caution

Rabies vaccinations

All 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(Required)

Please list the last two known Rabies vaccines separated by a comma. This information is required.

Rabies vaccination

If 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

If patient is not up to date on rabies, please explain:

If the patient is not up to date on rabies and bites or scratches anyone during their stay at the AUCVM, the patient would be subject to a home or clinic quarantine at the client’s expense. The Lee County Rabies Officer will make a recommendation on the appropriate quarantine action.

Service Referring To(Required)

Please enter all that apply

Reason for Referral(Required)

Patient History

We greatly appreciate you sending case information you have on your patient. Please send a copy of medical records. We request 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 and imaging.

What is your working diagnosis?(Required)

If you don’t have one, please state that.

Treatment

I plan to forward copies of the following patient information or have already done so:(Required)

Summary of Patient History

CBC

Biochem Profile

Urinalysis

Biopsy/Cytology Report

Radiographs

Serology

Endocrinology

Microbiology

rDVM Clinic Information

Please enter your clinic's contact information below.

Referring Veterinarian(Required)

Only one veterinarian's name please

First Last

Referring veterinarian's email(Required)

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(Required)

Clinic Address(Required)

Street Address City State ZIP Code

Clinic Phone(Required)

Clinic Fax

File Upload

Please upload supporting documentation regarding patient: Medical History, Vaccine Records, Labwork, and Imaging

File

Drop files here or

Max. file size: 24 MB.

Signature and confirmation

You 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(Required)

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