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?*
- Yes
- No
If yes, under what circumstances?*
Client Name*
First Last
Client Phone*
Patient Name*
Species*
- Dog
- Cat
Age*
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?*
- Yes
- No
Date Catheter Placed*
Date Format: MM slash DD slash YYYY
Volume Infused (ml)*
Fluid Used*
Additions to Fluid
Current Medications*
Click the "+" button on the right to add more medications.
Medication Name & Strength Frequency & Route of Administration Time of Next Dose
Should patient care protocol be determined by a SMAEC veterinarian?*
- Yes
- No
If no, what is the recommended patient care protocol?*
File Attachments
Please 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.

Medication Name & Strength	Frequency & Route of Administration	Time of Next Dose