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Date
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Doctor Name
*
First
Last
Practice Name
*
Laboratory Name
Doctor E-mail
*
Doctor Phone
*
Doctor Fax
How would you like to be contacted?
Phone
Email
Fax
Client Name
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First
Last
Patient Name
*
First
Last
Patient Species
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Dog
Cat
Other
Please upload lab reports, x-rays, and other diagnostics.
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Additional Upload (if necessary)
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Additional Upload (if necessary)
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Additional Upload (if necessary)
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Patient History
Diagnostic Information
Treatments / Medications
As the referring veterinarian, my expectations for this case are as follows: (Please check one.)
Referral for procedure(s)
Hospitalization and definitive care
Overall management of care for the diagnosis
Overnight care and return in the morning
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