Veterinary Referral Form for Endoscopy

Referring Veterinarian/Clinic *

Date *

Clinic Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

Email *

Preferred method of correspondence

Phone
Email
Fax
Mail

Patient Information

Owner’s Name *

Phone

Owner’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient’s Name

Age

Species

Weight

Breed

Sex *

Male
Female
Intact
Spayed/Neutered

Current on Vaccinations

Yes
No

Diagnosis/Reason for Referral

Type of Surgery and Date (if applicable)

List of Medications

Preexisting Conditions

A treatment plan will be individualized based on each patient’s needs. Endoscopy may be warranted immediately, or further analysis may be necessary prior to the procedure. It may include all or some of the following: Blood analysis, fecal analysis, treatment trials (dietary, deworming, supplementation, etc). Please list any dietary trials performed with this pet and level of compliance

* Please send or fax a copy of vaccine records, recent lab work, radiographs, and pertinent patient history.

* If you have any questions, please contact Rebecca Gerevics DVM, at (716) 695-7836 or pinewoodsanimal@gmail.com

* We would like to maintain a professional relationship with our veterinary partners. Please know this pet will be referred back to you for continued routine veterinary care.

* If the reason for referral is urgent such as gastric foreign body retrieval, please contact our office immediately and we will make every effort to accommodate this patient.

Endoscopy Form

Endoscopy Form

Veterinary Referral Form for Endoscopy

Patient Information

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