Emergency Referral Form

OPEN 24/7/365 For Emergencies

No Appointment Required

Emergency Referral Form

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(512) 817-3474

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Emergency Referral Form

If you are a veterinarian or clinic referring a patient for emergency care, please complete and submit the form below.

EMERGENCY REFERRAL FORM

Emergency Referral Form

EC TRANSFER REQUIREMENTS:*

Stable Patient

Diagnosis

Prognosis

Treatment Plan

All Above Discussed With Client

Client Name:

Phone:

Patient Name

Patient Age

Vaccines Current?

Yes

No

Referring Clinic

Referring DVM

Cell Phone Number

Tentative Diagnosis

Prognosis

Known Allergies

Last Time of Urination

Last Time of Vomiting

Last Time of BM

Free Text

Medications Given:

Medication #1

Medication #1 Amount

Medication #1 Route

Medication #1 Time

Medication #2

Medication #2 Amount

Medication #2 Route

Medication #2 Time

Medication #3

Medication #3 Amount

Medication #3 Route

Medication #3 Time

Free Text

Total Fluids Given:

Total Fluids Given (mLs)

Type:

Additives:

Free Text

Medications To Administer:

Medication #1

Medication #1 Amount

Medication #1 Route

Medication #1 Frequency

Medication #2

Medication #2 Amount

Medication #2 Route

Medication #2 Frequency

Medication #3

Medication #3 Amount

Medication #3 Route

Medication #3 Frequency

Free Text

Lab Procedures Requested:

Lab Procedure #1

Lab Procedure #1 Time

Lab Procedure #2

Lab Procedure #2 Time

Were Radiographs Taken?

Yes

No

If Yes, Will They Arrive By:

Email

Client

Was Labwork Run?

Yes

No

If Yes, Will They Arrive By:

Email

Client

Free Text

PLEASE EMAIL ALL CURRENT LABWORK, REPORTS, RADIOGRAPHS AND MEDICAL RECORDS TO

INFO@EAHOFCRYSTALFALLS.COM.

Be sure to have the referring veterinarian call and speak with an EC Dr.

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Emergency Referral Form

Emergency Animal Hospital of Crystal Falls FB Page

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