Equine Ophthalmology Consult and Referral Form [moved]

Veterinarian Contact Information

Standard Referral

The Ophthalmology service will contact the client to schedule an appointment within 2 business days.

Phone or Email consult only

An Ophthalmology clinician will contact you within 1 business day. Please pick this option if you would like to speak with an Ophthalmology clinician prior to referral or just for consultation.

Referral Status(Required)

Standard Referral

Phone or Email consult only

How would you like to be contacted?

Phone

Veterinarian to contact(Required)

Prefix First Last

Vet/Clinic Phone(Required)

Vet/Clinic Email(Required)

Clinic Name

Clinic Fax Number

Owner Contact Information

Name of Owner(Required)

First Last

Owner Phone(Required)

Owner Email

Address

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

Information about the patient

Patient/Pet Name(Required)

Date of Birth or Age(Required)

Gender/Sex

Color

Reason for referral/clinical history (include duration of illness, signs):(Required)

Major travel history in the last 60 days:

Any adverse reactions to sedation?(Required)

Yes

In the past 30 days, has the patient exhibited any clinical signs of an infectious disease, such as cough, nasal discharge, diarrhea, or fever?(Required)

Yes

Coggins test current? If yes, please email or attach results below. If no, please perform one and submit before the patient’s appointment(Required)

Yes

Please attach to this online form, send via email ([email protected]), or fax (919.513.6711), supporting information, such as eye photos, records, diagnostic test results, or radiographs/ultrasound reports.
Click here for tips on how to take eye photos with your smart phone.

File

Drop files here or

Max. file size: 195 MB.

NC State Estimate provided to owner (if any):

Low: $

High: $

Does the patient currently have a confirmed or suspected infectious disease or known/suspected multidrug-resistant infection (e.g., MRSA, MRSP, CRE, ESBL-producing organisms)?(Required)

Yes

Confirmed or suspect disease

Does this patient have a current or pending culture?(Required)

Yes