PET REFERRAL INFROMATION
SURGERY /INTERNAL MEDICINE/OTHER
Referral to:
Surgery
Internal Medicine
OTHER
Appointment Date and Time:...................................................................................................................................
Referring Veterinarian:..............................................................................................................................................
Practice:...................................................................................................................................................................
Address:.....................................................................................................................................................................
Contact –
Office:.......................
Mobile:.......................
Fax:...................................
Email:...........................................................................................................................................................................
Preferred method of reporting:
Email
Fax
Phone
Letter
Owner details:
Name:............................................................................................................................................................................
Address:.........................................................................................................................................................................
Contact –
Office:...........................
Mobile:.............................
Fax:...................................
Email:...........................................................................................................................................................................
Pet Details:
Name:..................................................... Species: Dog Cat
Other(Please specify):
Breed:............................................. Colour:............................... Age:......... Sex:
M
Weight:...........Kg’s
MN
F
FS
Primary Reason for Referral:.......................................................................................................................................
Case Summary:.......................................................................................................................................................................
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.................................................................................................................................................................................................
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Treatment to date:.........................................................................................................................................................
.................................................................................................................................................................................................
.................................................................................................................................................................................................
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Other Comments:..........................................................................................................................................................
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Please Enclose relevant radiographs, Full copies of relevant laboratory reports, radiology/ultrasound
reports etc. If insufficient space please attach additional sheets and/or history printout.
Charles Sturt University
Kay Hull Veterinary Teaching Hospital
132 Urana St, Wagga Wagga NSW 2650
Ph: 02 69334706
Email: [email protected]