Patient Referral Form - Keauhou Veterinary Hospital

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Patient Referral Form
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Date:!
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Referring Doctor: __________________ ! !
Referring Clinic/Hospital: _____________________!
Phone: _______________________ Fax: __________________________!
Email: _______________________!
Preferred contact method: ! Phone ! Fax ! Email ! Mail!
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Client name: ________________________ !
Home Phone: ______________ Work phone: ___________________ Cell phone: _______________!
Patient Name: ________________ Breed: ______________ Species: ! Canine ! Feline ! Other!
Sex: ! Female ! Male ! Spayed/Neutered Age: _____ Birthdate: __________________!
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Referred to: ! Surgery ! Internal Medicine ! Emergency ! Pain Management ! Other !
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Chief Complaint/ Tentative Diagnosis: !
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History/ Physical Findings:!
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Laboratory Data: (Please attach copies of results)!
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Treatments/Medications: (Please attach copies of results)!
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Radiographs sent with client: (films/CDs will be returned) ! Yes ! No!
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Note to Clients: Please bring this form and a list of all medications to your pet’s initial exam. At the time you make
your appointment, please ask if you need to withhold food or medications before your appointment. Fees are payable
in full at the time of services rendered. Payment may be made by cash, MasterCard, Visa, American Express or
Discover.
Keauhou Veterinary Hospital
Dr. Jacob Head
78-6728 Walua Rd., Kailua-Kona, HI 96740 Phone: 808-322-2988 Fax: 808-322-2303
Website: Email:

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