Surgical Consultation Referral
Clinic Name:
*
Clinic Name
*
Clinic Contact Information:
*
Clinic Phone
Clinic Email
Veterinarian Contact Information:
*
Veterinarian Name
Veterinarian Email
Client Contact Information:
*
Client Phone
Client Email
Client/Pet Information:
*
Client's Full Name
Pet's Name
Patient FAS Score
Please Select
1 Low - Relaxed
2
3
4
5 High - Aggression
https://fearfreepets.com/fas-spectrum/
Clinical history / presenting complaint:
*
Relevant diagnostics performed (e.g blood work, x-rays-include links if available):
*
ASA Score + Known precautions or concerns for anesthesia:
*
ASA Reference: https://www.avtaa-vts.org/asa-ratings.pml
Current medications:
*
Relevant Patient Records / X-Ray JPEGs
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