Please fill out the form below. If you have any radiographs and/or bloodwork, please email them to: DAHsurgeon@gmail.com

Client Name

First Name

Last Name

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Primary Phone Number

(###)

###

####

Client Secondary Phone Number

(###)

###

####

Client Email Address

Referring Veterinarian Name

Clinic Name

Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Clinic Phone

(###)

###

####

Private Phone

(###)

###

####

Clinic/Veterinarian Email

Enter Email (if different than previously listed) you want us to send your report to:

We no longer have faxing capabilities

Pet Name

Species

Breed

Age/Date of Birth

Sex

Neutered/Spayed?

Color

Last Weight in Lbs

Body Condition Score: */9

Patient's Temperament

Please select the following based on the patient's known history with your practice.

Vaccination History

Please indicate when the following vaccinations were given. If unknown, please leave blank.

Rabies

YYYY

1 year or 3 year

Rabies

DA2PPV

YYYY

1 year or 3 year

DA2PPV

Bordetella

YYYY

6 months or 1 year

Bordetella

FVRCP

YYYY

1 year or 3 year

Tentative Diagnosis

Indicate leg(s) of concern:

click all that apply

None

Left Rear

Right Rear

Left Front

Right Front

For Cranial Cruciate Ligament Ruptures (CCL)

If you are referring this patient for a Cranial Cruciate Ligament (CCL) Rupture at any point in the future if this patient begins having a suspected CCL rupture on the other leg, do you approve of them making an appointment directly with Dr. Montgomery rather than having to get a new referral?

Were Radiographs Taken?

Please email them as soon as possible prior to the patient's appointment time to dahsurgeon@gmail.com.

Date radiographs were taken (if applicable):

YYYY

Were Radiographs Emailed?

Email is: DAHsurgeon@gmail.com (If unable to email radiographs or we do not receive them prior to the scheduled appointment time, there is a chance that the client will have to pay to have radiographs repeated)

History and Previous Therapy

Known Allergies or Sensitivities

Current Medications

Date of referral:

YYYY