Exotic Pet Medicine Referral Form
Mahalo Veterinary Hospital
Today's Date
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Month
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Day
Year
Date
Referring Veterinarian Information
Referring Hospital
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Referring Veterinarian
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Phone Number
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Email Address
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Patient Information
Patient Name
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Species
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Age or Date of Birth
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Sex
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Male
Female
Unknown
Serilized
Weight
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Specify G or KG
Microchip or ID*
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*If any
Owner Information
First Name
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Last Name
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Address
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Phone number
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Email address
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Presenting Complaint
Main reason(s) for referral
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Duration of the problem
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Has the condition:
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Worsened
Improved
Remained stable
Medical History
Relevant husbandry parameters for this species (enclosure size, temperature, humidity, lighting, diet, co-housed animals, etc.)
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Relevant past medical history
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Reproductive status and history (if relevent)
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Vaccine status (for species where applicable)
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Diagnostics recently performed
Please attach results when possible
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CBC
Biochemistry
Radiographs
Ultrasound
CT/MRI
FNA, cytology
Fecal exam
Cultrues/PCR
None
Other
Current Medications
List all medications, dosages in mg/kg, and dates given
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Any supplements or topical treatments
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Response to treatment so far
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Expectations of the referral
Urgency Level
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Urgent
Routine Referral
What are you requesting
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Complete case transfer
Shared management
Specific diagnostic procedure
Treatment plan only
Additional notes or questions
*
Medical Records
Please attach the complete medical records, including all diagnostic results
File Upload
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