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Referring Veterinarian
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Name
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Clinic/ Hospital Address
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Hospital Phone (voice call)
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Email
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Client INFORMATION
Name
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First
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Address
*
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Zip Code
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Primary Phone Number
*
Please have the client call us at
985-888-1059
to schedule their first appointment.
Additional Client Information
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Email
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Patient Information
Patient Referred For
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Please Select
Surgery
Neurology
Physical Rehabilitation
Acupuncture
Custom Bracing
Hyperbaric Oxygen Therapy
LASER Therapy
Pain Management
Patient Name
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Breed
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Age
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Sex
*
Please specify
Male Neutered
Female Spayed
Male intact
Female Intact
Common Diagnosis
*
CrCL injury
Intervertebral Disc Disease (IVDD)
Fracture management
Osteoarthritis
Hip Disease
Elbow/ Shoulder disease
Soft tissue injury
Mass Removal
Seizure disorder
Lumbosacral Disease
Polytrauma
Unknown
Other Diagnosis (leave blank if unknown)
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Current Medications
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Please fill in any other pertinent information
History of medication allergies or adverse reactions
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Additional Information, Questions/ Concerns
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Records and/or diagnostic information
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Max file size: 20MB
Radiographs or large files can be emailed to resurge@resurge.vet
Thank you for your referral
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Home
Services
Veterinary Diagnostics
Surgery
Neurology
Platelet Rich Plasma (PRP)
Physical Rehabilitation
Hyperbaric Oxygen Therapy
Acupuncture and Traditional Chinese Medicine
About
Contact
Blog
Client Registration Forms
Veterinary Referral Information
Request an Appointment
Refill a Prescription