Veterinary Ophthalmology
Referral Form
Laurence E. Galle, DVM
Board Certified
Veterinary Ophthalmologist
Mobile,
AL
Phone: 251 633-9633
Fax:
251
633-3025
www.dukeanimalclinic.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.