Referral Form

Referral Form
Referring Hospital Information
Date*

MonthDayYear
Date
Hospital Name*
Referring Veterinarian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
All case updates will be provided via email.
Referral service requested:*

EmergencyCritical CareOvernight Care ProgramOther
Please mark one:*

Urgent ReferralStable Referral
All referrals marked "urgent" need to call our patient care coordinator after this form is submitted to discuss the case. This must be done prior to transferring the patient to our facility.
Client Information
Owner Name*

First NameLast Name
Title
Dr., Mr., Mrs., etc.
Spouse/Co-Owner Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Phone*
Please enter a valid phone number.
Spouse/Co-Owner Phone
Please enter a valid phone number.
Patient Information
Name*
Age*
Birth Date
Sex*

MaleMale, neuteredFemaleFemale, spayed
Species*

CanineFelineOther
Breed*
Color/Markings*
Microchipped?

YesNoUnknown
Insurance?

YesNoUnknown
Insurance Provider
Is the pet up-to-date on their rabies vaccine?*

YesNo
List any current medications (including over-the-counter supplements and preventatives, if none write "None")*
Has this patient required pre-visit pharmaceuticals, nutraceuticals or other interventions to reduce FAS at your practice?*

YesNoUnknown
Has this patient required sedation for procedures due to elevated FAS?*

YesNoUnknown
Please provide any additional information regarding management of this patient's FAS, including any successful interventions, medications (with dosages), triggers, likes, dislikes, etc.*
We recommend referring veterinarians evaluate the patient's FAS and overall stability prior to transport, especially if traveling long distances. This could include use of antiemetics, PVPs or other FAS reducing interventions, or any additional stabilization as deemed appropriate.
Case Summary
How can we help? (Tentative diagnosis(es), issues prompting referral. Please list any specific procedures requested or discussed with the client.)
History of Present Illness (clinical signs, date of onset, duration, progression, severity, etc.)
Summary of Clinical Findings (pertinent diagnostic results, physical exam findings, pending diagnostics)
Current Treatments (Include any current or previous treatments associated with this illness along with response if applicable. For urgent referrals, please list any treatments in-clinic along with dose and the time given.)
Additional Comments (anything else we should know, specific questions, comments or concerns)
Upload Radiographs

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Upload Labwork

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Upload Patient Chart

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Upload Photos/Pertinent Documents

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If you prefer to send patient records and diagnostics via email, please do so at:
referrals@mosaicanimal.com
Should be Empty:

Referral Form

Referring Hospital Information

Client Information

Patient Information

Case Summary