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Overnight monitoring transfer form

Please fill out this form as completely and accurately as possible so we can best facilitate the transfer process.

Patient Information

Patient Name *

Breed *

Age *

Sex *

Neutered *

Client Information

Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Phone number where you can be contacted during your pets procedure

Email *

Referral Information

Referring DVM name *

Clinic Name *

Clinic Contact Phone *

Clinic Contact Email *

Patient History

Problems/concerns/reason for referral (i.e. post-op, needs fluids overnight, etc): *

Historical concerns: *

Abnormal physical exam findings: *

Labwork results: *

Imaging results: *

Abnormal physical exam findings:‬ ‭ *

Known medication/sedation sensitivities, or preferred sedation if needed: *

Treatment Plan

Goals (i.e. monitor overnight and send home in the morning; fluids overnight and return‬ ‭ to referral clinic in the morning, etc):‬ ‭ *

If the patient needs to be hospitalized longer than expected, can they return to the‬ ‭ referral clinic if appropriate?

Fluids:‬ ‭ *

Medications: *

Any other notes/treatments/procedure/imaging: *

Notes:

The medical record, anesthesia record, and discharge instructions must accompany the patient.
Any medications to be dispensed should be sent with the client. A bag of IV fluids should also be sent if the patient requires fluids. Additional charges will apply if this is not done.
We will briefly discuss the case with the client on arrival before the patient is dropped off.
All patients must be picked up by 8:00 AM the following morning.
Clients will be advised that if further monitoring is needed after 8:00 AM, they will either:
- Take the patient back to the primary veterinarian (as indicated on this form), or
- Be directed to a local emergency clinic.
A 100% deposit for the cost of overnight monitoring is required prior to drop-off. An estimate will be provided to both you and the client beforehand.
This referral form does not cover additional procedures such as:
- Wound repair
- Sedated bandage changes
- Unblocking
- Placement of feeding tubes

If your patient requires any of these procedures, please contact us by phone.

Overnight Monitoring Transfer Form