Gulf Shores Companion Animal Referral Form InstructionsThe following form is to be used by veterinarians who are referring a non-emergent case to Auburn Veterinary Specialists in Gulf Shores, AL. 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 at Auburn Veterinary Specialists 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 (gsderm-ticket@vetmed.auburn.edu, gsim-ticket@vetmed.auburn.edu, or gssurg-ticket@vetmed.auburn.edu) or fax (251-930-6278). 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 call 251-227-8480. 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*Has this client had a pet seen at Auburn University CVM before?* Yes No Not Sure Has this patient been seen at Auburn before?* Yes No Not Sure Appointment SchedulingWe will call the client to schedule their appointment.Patient InformationPatient Name* Species* Dog Cat Ferret Other If other, please specify* Patient Breed Patient WeightPlease enter weight in lb or kg Patient's Age (years-months )*years - months (3-10) Patient's Sex* Male Male (neutered) Female Female (spayed) Temperament* Friendly Use caution 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 251-227-8480.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 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* Dermatology Internal Medicine Surgery Reason for Referral*Patient HistoryWe 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?* If you don’t have one, please state that.TreatmentI 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 FaxFile UploadsPlease upload supporting documentation regarding patient: Medical History, Vaccine Records, Labwork, and Imaging. Drop files here or Select files Max. file size: 49 MB. Signature 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
