Veterinary Ophthalmology Referral Form

Laurence E. Galle, DVM

Board Certified Veterinary Ophthalmologist

Ocean Springs, MS & Mobile, AL

Phone: 228-872-2755

Fax: 228-872-3846

E-mail: peteyecare@gmail.com

Client and Patient Information

Date: ______________

Client Name: _________________________________________________________________________

Primary Phone: ( ) _______________________ Additional: ( )__________________________

Patient Name: ______________________________ Breed: _________________________________

Sex: F FS M MN Pet Birthdate: _____/_____/_________

(mm) (dd) (yyyy)

Primary Veterinarian Information

Primary Care Hospital: ___________________________ Veterinarian: ___________________________________

Phone: ________________________________________ Fax:__________________________________

Email: ________________________________________

Preferred method for written referral communication: Mail / Fax / Email

Reason for Referral:

Y N Have you done diagnostic blood work in the past month? If so, please send results.

Y N Has the patient undergone anesthesia in the past month? Please note above.

Y N Is the patient current on vaccinations and parasite control?

How would you rate the patient’s suitability for general anesthesia?

In order to better serve you, your clients, and your patients, we ask that you please complete and fax this form or have a staff member contact us BEFORE your client calls to schedule an appointment. This will ensure that only your requested referral patients will be scheduled for an appointment.