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evsroanoke@gmail.com
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Referral Form
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Referring Doctor
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Referring Hospital
Phone
*
Email
*
Prefer to be contacted by
*
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If not, the doctor on duty will treat as s/he feels appropriate.
Owner Name
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Client Email Address
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Patient Name
Breed
Age
Weight
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Presenting Complaint:
Physical Exam:
Laboratory Test/Special Procedures:
Medication Given:
How much?
Time Given:
Medication Given:
How much?
Time Given:
Medication Given:
How much?
Time Given:
Medication Given:
How much?
Time Given:
Medication Given:
How much?
Time Given:
Medication Given:
How much?
Time Given:
Recommendations for Treatment Plan:
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Please inform clients of the following:
1. At EVS, they will be given an itemized estimate and asked to leave a deposit of the low end of the estimate.
2. Remaining fees are due and payable when the patient leaves EVS. We accept cash, all major credit cards,
Scratchpay
, and
Care Credit
.
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