Peticare Form - Specialist Referral Form (Internal Medicine)
What type of referral is this?
In house consult
Case Transfer
Date
/
Month
/
Day
Year
Date
Patient no
For your reference
Patient Name
eg. Momo
Sex Weight
eg. MN 5.4kgs
Age
eg. 11y5m
Species & Breed
eg. Feline DSH
Client Contact Tel
eg. 9999 9999
Referring Vet and Vet Clinic
eg. Dr. Chan from XXXX Animal Hospital
Referring Vet Clinic Email
example@example.com
Provisional diagnosis
Reason for Referral:
Diagnostics procedures (Diagnostic results will be discussed with the client by primary vet)
Management advice (Diagnostics and treatment recommendations will be provided via medical notes only)
Full Case Transfer to specialist
Other
Owner consent for referral including cost clarification done before referral:
Yes
No (Please help to clarify minimal costs for consult and testing)
Urgency:
Emergent (Today)
Urgent (within 2 days)
Non-Emergent (during hospitalisation)
Back
Next
If you are referring your case not from a Peticare branch, please upload any patient history or images of reference.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Please print out the checklist on page 2 and 3 of this pdf for your client in preparation of their Internal Medicine Specialist Appointment after you receive a copy of this filled in form via your email inbox.
Preview PDF
Submit
Should be Empty: