Post-op monitoring referral form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Patient Name(Required)

Breed(Required)

Age/D.O.B(Required)

Sex(Required)

Neutered(Required)

Yes

No

Client Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number(Required)

Email(Required)

Referring DVM name(Required)

Clinic Name(Required)

Clinic Contact(Required)

Problems/concerns/reason for referral (i.e. post-op, needs fluids overnight, has a specific complication, etc)

Historical Concerns

Abnormal physical exam findings

Labwork Results

Imaging Results

Known medication/sedation sensitivities, or preferred sedation if needed

Goals (i.e. monitor for a few extra hours after surgery, discharge when comfortable)

Fluids(Required)

Type

Rate

Additives

Medications(Required)

Medication, mg dose, route, frequency

Last given

Next due

Any other notes/treatments/procedure/imaging

Notes:

The medical record, anesthesia record and discharges must accompany the patient.
Any medications to be dispensed should be sent with the client. A bag of IV fluids should also be sent with the client if the patient should be on fluids. Additional charges will incur if this is not done.
We will briefly discuss the case with the client on arrival before dropping off.
All patients must be picked up by 2am when the clinic closes.
Clients will be advised that if the patient needs further monitoring after 2am, then they will either be directed to take the patient back to a local ER.
We require a 100% deposit for the cost of post-op monitoring prior to dropping the patient off. We will provide an estimate to you and the client prior to arrival.
This referral form does not cover any procedures that may need to be performed such as wound repair, sedated bandage changes, unblocking, placement of feeding tubes, etc. If your patient needs any of these procedures, please contact us via phone.

Post-op Monitoring Referral Form