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Home
Services
About
For Veterinarians
Premium Products
Exercise Program
News
ARF Fit Club
Contact

Patient Referral Form

Patient Referral Form

Step 1 of 3

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Referring Information
Doctor's Name
Prefix First Last
Hospital Address
Street City State ZIP Code
Phone
Fax
Email

Client Information
First Name Last Name
Street Address City State ZIP Code
Phone
Email

Patient Information

Name
Species
Breed
Date Of Birth
Month
Day
Year
Sex
- Male
- Female
- Neutered
- Spayed
Rabies Vx History
Patient History
Does this patient have a history of any of the following conditions?
- Seizures
- High/Low Blood Pressure
- Heart Murmur/Arrhythmia
- Diabetes Mellitus
- Renal Disease
- Bloat/GDV
- Blood Disorder (please describe below)
- Skin condition (please describe below)
- Other (please describe below)
Note: Please use this area to include additional information or conditions.
Physical Findings
Diagnostic Test Results
- Radiographs Emailed
Current Treatments
Medications and Dosages
Diagnosis, Date & Type of Surgery, if applicable
Special Requests / Comments
Please be sure to include any surgical reports or patient discharge instructions with this report.

Office Hours

Monday Closed
Tuesday 1PM-8PM
Wednesday 9AM-6PM
Thursday 1PM-8PM
Friday 9AM-6PM
Saturday 11AM-5PM

Information

Email
info@K9RehabMI.com

Doctor's hours by
appointment only.

Phone

Phone
(734) 253-2722

Fax
(734) 253-2736

Location & Directions

Animal Rehabilitation Facility
8040 4th Street
Dexter, MI 48130

Driving Directions

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