AEC Referral form

Referral Details

Patient Details

Sex
X
Male
X
Female

De-sexed
X
Yes
X
No

Referral to Animal Emergency Care for

X
A - Overnight Care

If there are any concerns overnight then please contact:

X
Name Contact Number

X
AEC Vet (or if above contact unable to be reached) - $30 surcharge applicable.

Treatments required overnight:

Medication Dose needed (mgs) Route Frequency Time last given

Fluid therapy required overnight:

X
IV catheter care only – IV to stay in place but no fluids required.

X
Fluid Type Rate mls/hr.   Rate Volume given prior to arrival:mls

All Overnight Care patients are discharged back to their referring vets prior to 9am the next morning.

If receiving your patients back at this time is not convenient then please phone AEC to discuss options.

X
Please invoice our Client

X
Please invoice our Practice (call AEC to organise if using this option for 1st time)

X
B - Further assessment and treatment

Please contact AEC to discuss your patient’s needs and to obtain an estimate of costs likely to be incurred.

Full Patient History:
X
Emailed/Faxed
X
Sent with Patient
X
Attach Browse
Lab Results:
X
Emailed/Faxed
X
Sent with Patient
X
None
X
Attach Browse
Radiographs:
X
Emailed
X
Sent with Patient
X
None
X
Attach Browse






By submitting this form you acknowledge that if, on arrival, a patient is assessed by an AEC vet as not
meeting the criteria for Overnight Care, then AEC will provide further treatment as per referral Option B.

If contact details have been provided then AEC will make every attempt to contact referring vets should this happen.

Thank you for entrusting us with your patient’s care