Gulf Shores Referral Form - Auburn University College of Veterinary Medicine

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

We will call the client to schedule their 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 251-227-8480.

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)

Dermatology

Internal Medicine

Ophthalmology

Surgery

Reason for Referral(Required)

Patient History

We greatly appreciate you sending case information you have on your patient. Please send a copy of the current medical record. Please send results of diagnostic testing.

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)

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 Uploads

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

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

Gulf Shores Companion Animal Referral Form