Thank you for referring your client to Pets in Balance Veterinary Care. Please email records from the last year to drlisa@petsinbalancevet.com or fax to (312) 724-7099. Your time in completing this form is greatly appreciated.
Name:
Clinic:
Address:
Phone:
Fax:
Email:
Preferred method of contact:
Species:
Breed:
Color:
Age/Date of Birth:
Sex:MaleFemale
Spayed/Neutered:SpayedNeutered
Most Recent Weight:
Reason for referral:
Pertinent medical history and physical exam findings:
Diet:
Medications and Supplements:
Previous diagnostics:
Previous treatments:
Any allergies, adverse reactions, or handling issues?:
Other veterinarians managing this patient's care that you recommend we contact:
