Referral Form

Diagnosis:*

Previous treatment & time it was performed:

Current treatments to be continued:

Labwork performed & when it was completed:

Labwork requested to be performed through AEC:

Radiographs sent to AEC with patient?*

yes
no

Radiographs to be performed at the AEC?*

yes
no
As needed only

Guidelines:

Treatment sheets must be prepared by rDVM
Please do not send medications except:
- oral medications
- current IV bag
- injectable medications that have been reconstituted, labeled w/strength(mg per ml),date & time of reconstitution
ALL medications must be accurately labeled or will not be given
Owner and rDVM phone numbers must be available should patient condition require deviationfrom treatment protocol.

Charges:

Entrance exam fee: $60.00
Daily evaluation exam fee: $50.00 (every 24 hrs)

If patient condition changes or an alternate/additional diagnosis is determined by the AEC staff, the AEC reserves the right to deviate from the minimal intervention program WITH CONSENT of owner or rDVM. The AEC will do their best to inform them in the event of an emergency situation where a life-threatening problem occurs.

I am requesting the above protocol for my client.

Client name*

Client phone number*

Client Email (fill this out if you would like to recieve copy)

Referring DVM's email (fill this out if you would like to recieve copy)

Referring DVM*

rDVM phone number(s)*

Password:*

As always, please forward a complete medical record for each patient to the AEC prior to transferring or referring your client

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