E-mail: info@willitsvet.com | Office: (970) 510-5436

CT Referral Form - Willits Veterinary Hospital





Please bring this form to your pet’s imaging appointment. Please withhold food for 12 hours prior to your appointment unless otherwise directed.

 

Print form and send via mail: Printable Form

Today’s Date:

Referring Hospital:

Referring Doctor:

 

Referring Doctor Contact Information

Phone:

Fax:

Email:

 

Client Contact Information

Client Name:

Home Phone:

Work Phone:

Cell Phone:

 

Patient Information

Patient’s Name:
Species:
Breed:
Age:

Sex:

Tentative Diagnoses/Chief Complaint:

History/Physical Findings:

Laboratory Data:

Special Requests/Comments:

 

Consent

I hereby consent to and authorize the performance of such procedures or operations as are necessary and desirable in the exercise of the veterinarian’s professional judgement. I also authorize the use of appropriate anesthetics and other medications as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure or operations and the risks involved.

I hereby consent to: IVC & fluids

General Anesthesia

Sedation