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Referring Doctor*
Hospital Name*
Phone
Fax*
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Hospital Address*
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Owner's Name*
Owner's Address
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Species*
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Any History/Pre-existing conditions (including surgical procedures and dates)*
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Diagnostics Performed/Pertinent Results
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Special Requests/Comments
We also request that the patient's complete medical record (via attachment, fax or email) is sent ahead of the patient consultation, so that the specialist has ample time to review it. Please include any lab work and/or imaging studies, in addition to this referral form.