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Veterinary Referral Information
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Referring Veterinarian
*
Required fields
*
Indicates required field
Name
*
First
Last
Clinic/Hospital Name
*
Clinic/ Hospital Address
*
Line 1
Line 2
City
State
Zip Code
Country
Preferred form of communication
*
Please select
Hospital Phone (voice call)
Cell Phone (voice call)
Text Message (cell required for this option)
Email
other (please specify below)
Other
*
Hospital Phone
*
Fax
*
Cell Phone Number
*
Email
*
Client INFORMATION
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Primary Phone Number
*
Scheduling first appointment (choose 1)
*
Have Resurge contact the client to schedule
Referring doctor will have client call Resurge to schedule
Additional Client Information
*
Email
*
Patient Information
Patient Referred For
*
Please Select
Surgery
Physical Rehabilitation
Custom Bracing
Hyperbaric Oxygen Therapy
LASER Therapy
Pain Management
Patient Name
*
Breed
*
Age
*
Sex
*
Please specify
Male Neutered
Female Spayed
Male intact
Female Intact
Common Diagnosis
*
CrCL injury
Intervertebral Disc Disease (IVDD)
Fracture management
Hip Disease
Elbow/ Shoulder disease
Soft tissue injury
Mass Removal
Polytrauma
Unknown
Other Diagnosis (leave blank if unknown)
*
Current Medications
*
Please fill in any other pertinent information
History of medication allergies or adverse reactions
*
Additional Information, Questions/ Concerns
*
Records and/or diagnostic information
*
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
Surgery
Physical Rehabilitation
Hyperbaric Oxygen Therapy
Platelet Rich Plasma (PRP)
Veterinary Diagnostics
About
Contact
Blog
Client Registration Forms
Veterinary Referral Information
Refill a Prescription
Request an Appointment