Retinal Reattachment Referral Form
Referring Ophthalmologist Information
Doctor Name
*
Practice Name
*
Practice Phone Number
*
XXX-XXX-XXXX
Practice Email
example@example.com
Owner Information
Owner's Name
*
Owner's Phone Number
*
XXX-XXX-XXXX
Owner's Email
example@example.com
Patient Information
Patient's Name
*
Patient's Sex
*
Male
Female
Male Neutered
Female Spayed
Species
*
Canine
Feline
Horse
Rabbit
Chicken
Pocket Pet
Breed
*
Age in Years
*
Eye Involved
*
Left
Right
Both
Does the patient currently have cataracts?
*
Yes
No
When did the patient first show signs of vision loss?
*
Which of the following diagnostics have been performed? (check all that apply)
*
Ocular Ultrasound
ERG
Blood Pressure
Tonometry
Please provide information concerning this case (case history, clinical signs, diagnostic results, tentative diagnosis, any concerns):
*
Is the patient taking any medications? If not, list N/A
*
Please upload case files (including ultrasound images when available):
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