Saving lives, making a difference, for pets.

Services

425.823.9111
11814 - 115th Ave NE
Suite 102
Kirkland, WA 98034

New Patients

Referring Hospital Information:
Referred By Dr.
Referring Hospital:
Phone:
Fax:

Client/Patient Information:

Name of Client:

Phone #1:

Phone #2:

Patient's Name:

Species:

Breed:

Sex:

Age:

Triage status
(check all that
apply)

	non-ambulatory – may require stretcher
	oxygen-dependent – triage to oxygen cage
	possibly contagious – triage to isolation

Signalment:

History:

Diagnostics:

Treatment/medications:

Plan/rDVM expectations:

Verification:
		copy the digits from the image into this box

Send the images with the client and fax all other history, lab work, treatment, etc. Thank You!

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