AEC Referral Form - Perth Vet Specialists

Referral Details

Veterinary Practice*

Vet's Name*

Name*

Surname*

Breed*

Age*

Sex*

Male
Female

De-sexed*

Yes
No

Current Problems*

Referral to Animal Emergency Care for:*

A - Overnight Care
B - Further assessment and treatment

Treatments required overnight:

Medication	Dose needed (mgs)	Route	Frequency	Time last given

If there are any concerns overnight then please contact:*

Supply a name & contact number
AEC Vet (or if above contact unable to be reached)

Name*

Contact Number*

Fluid therapy required overnight:*

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

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.

Who should we invoice?*

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

Full Patient History:*

Emailed/Faxed
Sent with Patient
Attach

Attachments*

Drop files here or

Lab Results:*

Emailed/Faxed
Sent with Patient
Attach

Attachments*

Drop files here or

Radiographs:*

Emailed
Sent with Patient
Attach

Attachments*

Drop files here or

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.

305 Selby Street North, Osborne Park, WA 6017
Phone	08 9204 0400
Fax	08 9204 5677
Email	perthvetspecialists.com.au