Emergency or Critical Care Emergency Critical CareReferred by Dr:Referring HospitalAddressPhoneCellFaxEmail How would you like to be contacted? Phone Fax Email U.S. MailDid you fax Pertinent Medical Records Blood Work Histopathology Ultrasound Reports Send Rads w/clientDid you tell client No food after 10pm H20 is OK Bring Rads from RDVM Bring all current medicationsName of Client:Address of Client:Home PhoneCell PhoneWork Phone:EmailPatient's NameSpeciesBreed:Sex: F SF M CM UnknownAge:Color:Tentative Diagnosis/Chief Complaint:History/Physical FindingsMost Recent Vaccination (date & type):Treatments (include medications and dosages):Laboratory Data (Attach copies of results):Max. file size: 128 MB.Special Requests/Comments
