Referral / Transfer Patient Submission Form This form is for referring veterinarians to fill out please. Back to homepage Date MM DD YYYY Referring Vet Clinic * Referring Vet Clinic Email * Referring Veterinarian Name * First Name Last Name Referring Veterinarian Afterhours Phone number * Please add a personal phone number so that we can call you to discuss the case afterhours if needed. (###) ### #### Client Name * First Name Last Name Client Phone number * Please ensure an emergency contact phone number is provided. (###) ### #### Client Address * Client Email address * Patient Name * Patient signalment * Age, sex, desexing status please Brief clinical history * Please briefly describe clinical history, and reason for overnight care / transfer Medications * Please list all medications that the animal is currently on - medication, strength, frequency, route of administration. Does your patient require IV fluids overnight? * Yes, the patient already has an IV line in. (Please ensure that the patient has an appropriate extension set attached, and that the line has been flushed with heparinised saline before travel. There is no need to send fluid bags with the patient.) Yes, A+Vet to put on IV fluids please. No, not at this time, unless clinical needs change. Does your patient require medications overnight? * Yes, these will be provided and sent with the patient. (Please ensure that they are appropriately labelled and packaged.) Yes, A+Vet to provide as described. No, not at this time, unless clinical needs change. Is the patient stable? Describe further in clinical history if needed. * Yes No Expected time of arrival Method of patient transfer Clinic dropping patient off Client dropping patient off Referral instructions A nurse will be available to receive patient referrals from 5.30pm on weeknights, and any time during the weekend. If you would like to discuss the case before referral please call us. Please ensure that your client is aware that payment will be required at the time of service. If you have any other notes to add, please write them here. Thank you! Your patient transfer referral has been received.
