Referring Veterinarian Case Transfer Form Referring Clinic*Date* Date Format: MM slash DD slash YYYY Referring Veterinarian* First Last After Hours Phone*Would you like to be contacted by SMAEC?*YesNoIf yes, under what circumstances?*Client Name* First Last Client Phone*Patient Name*Species*DogCatAge*Weight (kg)*Breed(s)*Color(s)*Patient History*Please provide copies of current lab work by attaching files at the bottom of this form.Diagnosis or Tentative Diagnosis*Is the patient on IV fluids?*YesNoDate Catheter Placed* Date Format: MM slash DD slash YYYY Volume Infused (ml)*Fluid Used*Additions to FluidCurrent Medications*Click the "+" button on the right to add more medications.Medication Name & StrengthFrequency & Route of AdministrationTime of Next Dose Should patient care protocol be determined by a SMAEC veterinarian?*YesNoIf no, what is the recommended patient care protocol?*File AttachmentsPlease upload current lab work and any additional documentation here. Drop files here or Accepted file types: txt, rtf, pdf, doc, docx, xls, xlsx, jpg, jpeg, tif, tiff, png, gif.
