Patient Referral Form

Patient Referral Form
Please complete our online Patient Referral Form below to refer a patient to Ebensburg Animal Hospital. Our preferred method of receiving forms is via an email sent to eahsurgery@gmail.com. If you are unable to send it to us via email then please fax us at (814) 471-6907.
Specialty Referral To
Referring Veterinarian
Dr. Name

First NameLast Name
Clinic/Practice Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Email
example@example.com
Patient Information
Client (Owner)

First NameLast Name
Client (Owner) Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client (Owner) Email
example@example.com
Patient Name
Patient Breed
Patient Classification
Gender
Neutered / Spayed?
Patient Age
Patient Color
Vaccinations (Date of Last): Distemper

MonthDayYear
Date
Vaccinations (Date of Last): FeLV

MonthDayYear
Date
Vaccinations (Date of Last): Rabies

MonthDayYear
Date
Vaccinations (Date of Last): HWT

MonthDayYear
Date
Medical Details
Current Problem (please indicate/describe chief complaint / onset / progression / treatments)
Significant Past Medical History / Problems
Tentative Diagnosis Given to Client
Diagnostic Tests
Treatment / Medications
Additional Comments
Additional letter / information sent with client?
Other Information Provided

Other
File Upload

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Referring Veterinarian