Client & Patient InformationPatient Name* Patient Species* Canine Feline Breed AgeGender* Female Male Reproductive status Intact Spayed Neutered Client Name* Client Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client Phone(s)* Referring Veterinarian & Clinic InformationReferring DVM* Hospital* PhoneFaxEmail After hours contact name* After hours contact phone*Time to call* Call me any time Call me any time before (specify below) **In all cases, the referring DVM must provide contact information for after hour’s contact in case of emergency**Time* : Hours Minutes AM PM AM/PM After this, please contact the client.Brief Case HistoryPlease include all pertinent information including but not limited to laboratory and other diagnostic reports, concerns, current Rx (including pre-, peri- and post-op). Hard copy radiographs will be promptly returned if provided with client.Attachments Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, doc, docx, Max. file size: 5 MB, Max. files: 5. Type of Referral* Overnight care and return in the morning Overnight care and discharge home from Four Seasons; send discharge instructions Case transfer for hospitalization, diagnostics and treatment As the referring veterinarian my expectations for this case are as follows (check one):Add on the following procedure(s) Repeat radiographs, blood work, etc.Checklist Four Seasons Veterinary Specialists contacted (970) 800-1106 Treatment form with treatment plan filled out and faxed All medications, IVF and treatments provided to owner for overnight care Injectable controlled substances brought by veterinary staff to Four Seasons Vet Specialists IMPORTANT NOTE: In recognition of changes in patient condition, doctor’s evaluation and client wishes, Four Seasons Veterinary Specialists reserves the right to change diagnostic or therapeutic plans for any patient when good clinical judgment dictates. PhoneThis field is for validation purposes and should be left unchanged. Δ
