rDVM Referral Form rDVM INFORMATION Hospital Name: Referring Veterinarian: Hospital Phone:Fax:Email: Preferred method to update you on case: Phone Fax Email Best Time to Call: Hours : Minutes AM PM CLIENT INFORMATION Client Name: First Last Home Phone:Cell Phone: PATIENT INFORMATION Patient Name: First Last Species/Breed: Age: Weight: Vaccinations Current? Yes No Sex: Male Male - neutered Female Female - spayed PATIENT MEDICAL INFORMATION Condition of Patient: Healthy Stable Critical Moribund Allergies?Presenting Problems/Diagnosis:DiagnosticResults/Treatments/Medications:Concerns/Requests:Service Requests:Post-Op Requests: Cold Laser Therapy Monitoring overnight & transfer back to rDVM Total Post-Op care (including follow up visits) Outpatient Surgery Only Surgery Consultation Only Other Rehabilitation Services Referral DIAGNOSTIC INFORMATION Are there any cardiac concerns? Allergies? PresentingProblems/Diagnosis:DiagnosticResults/Treatments/Medications:Service Requests: Evaluate and Treat – May include PROM, TENS unit, Cryo/Thermal therapy, therapeutic exercises, underwater treadmill, and home therapy development. Underwater Treadmill Only - Wellness/weight loss/conditioning. DOCUMENTS & RECORDS Check all that apply: Medical Records/Diagnostic Results Attached Medications sent with patient Radiographs sent with patient Radiographs Attached Please submit pertinent medical records and information about the pet’s medical condition, if available.Max. file size: 128 MB.