Veterinary Ophthalmology Referral Form




Laurence E. Galle, DVM

Board Certified Veterinary Ophthalmologist

Mobile, AL

Phone: †† 251 633-9633

Fax: †††††† 251 633-3025


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 patientís 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.