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2022-01-19T00:14:38+08:00
Please note: This form is for veterinary GP use only. If you are a pet owner, please contact us by
phone or email
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REFERRAL DETAILS
Service for Referral *
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SURGERY
ONCOLOGY
INTERNAL MEDICINE
SPECIALIST IMAGING
ANAESTHESIA
DERMATOLOGY
ANIMAL CRITICAL CARE
Additional imaging options
Telerad – written
Telerad – verbal
CT scan
Ultrasound
MRI
Urgent Referral
Yes
No
PATIENT INFORMATION
Select Species
DOG
CAT
BIRD
REPTILE
SMALL MAMMAL
OTHER
Sex *
MALE (ENTIRE)
FEMALE (ENTIRE)
MALE DE-SEXED
FEMALE DE-SEXED
Infectious
Yes
No
CLIENT INFORMATION
REFERRING VETERINARIAN INFORMATION
PATIENT FILES
Medical Records
Lab Results
Diagnostic Images
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