BLUEGRASS VET VISION RDVM SUBMISSION FORM

Dr. Erica Tolar DVM, DACVO
Dr. Erica Tolar DVM, DACVO

500 N. English Station Road Suite 111

Louisville, KY 40223

502-242-5504 (p) 502-677-0015 (f)

bluegrassvetvision@gmail.com
Primary Care Veterinarian
Clinic Name
Clinic Email
example@example.com
Clinic Phone
Format: (000) 000-0000.
Clinic Fax
Please enter a valid phone number.Format: (000) 000-0000.
YesNoTonopenTonovet
EmailFax
Owner Information:
Name
Address
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Pet's Name
Species
Breed
Weight
MaleFemaleSpayedNeutered
Date of Birth

MonthDayYear
Date
Color
Temperament
Reason for Referral/Provisional Diagnosis
History and underlying comorbitities
Ophthalmic Findings
Current Treatment/Medications
If lab work has been performed in the last three months please attach copies.

Lastly please have your client reach out for an appointment.
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Dr. Erica Tolar DVM, DACVO