Surgery Referral
Please fill this form out entirely and upload the required documents at the end of this form to refer a patient to Dr. Frank. Let your client know we will follow up with them once we've reviewed all of this information.
Name of Clinic Referring the Patient
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Phone Number of Referring Clinic
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Please enter a valid phone number.
Diagnosis
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What surgical procedure is needed? Include anatomical description. (For example, Left TPLO, Right elbow osteotomy, etc)
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Name of Person Filling Out the Form
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Patient and Client Information
Name of Client
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First Name
Last Name
Phone Number of Client
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Please enter a valid phone number.
Type of Phone Number
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Mobile
Landline
Address of Client
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email of Client
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example@example.com
Name of Patient
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Species
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Canine
Feline
Breed
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Color
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Weight
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Birthdate of Patient
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Sex of Patient
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Female Spayed
Male Neutered
Female
Male
List all Current Medications and Supplements the Pet is Taking
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Does this pet have any major health issues (diabetes, kidney disease, etc)?
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Does this pet have any behavioral issues that we should be aware of? (requires muzzle, requires sedation for exams, etc)
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When was the pet last Rabies Vaccinated? (Pets must be current on Rabies Vaccine for Surgery)
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Month
-
Day
Year
Date
Was this Rabies Vaccine a 3 year or a 1 year vaccine?
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3 year
1 year
Other
Was the owner given any idea of the price range that is typical of this treatment/surgery? If yes, what range was given?
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Does the Patient have any pending appointments at your clinic where the required bloodwork or radiographs will be performed? If so, when are they scheduled for?
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Required Uploads
Please use this area to upload the required documents for us to move forward with the referral. Please note, we will not be able to move forward with this referral until all files are uploaded and sent. If an item cannot be uploaded to this form, it can be sent to ironmountainanimalhospital@gmail.com - but please know we cannot start working on this referral until all required elements have been completed.
Please upload full medical records, including detailed doctor's notes, here:
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Please upload the required pre-operative bloodwork (Chemistry and CBC are required, 4dx is helpful if one has been done), here:
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If you have not performed bloodwork yet, and would rather have the client complete the required bloodwork at our clinic, please indicate that here:
If this is an orthopedic case, please upload the required radiographs here (R and L Lateral Stifle and V/D of the hips if a knee surgery are the minimum required shots - if any other ortho case, then just whatever is relevant to the issue):
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