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info@rutlandvet.com

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Veterinary Forms

If you are a veterinarian, please fill out either the veterinary referral form, ultrasound referral form, or urinalysis questionnaire.

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Veterinary Referral Form
Ultrasound Referral Form
Chiropractic Referral Form
Urinalysis Questionnaire

Referring Veterinarian *

Hospital Name *

Daytime Phone

Evening Phone

Fax

Email *

Referring Veterinarian Preference for initial communications *

Telephone
Fax
Email

Client Name *

First

Last

Patient Name *

Client Phone *

Species *

Canine
Feline

Sex *

Male
Neutered
Female
Spayed

Breed *

Weight *

DOB/Age *

History

Physical Exam Findings

Related Laboratory and /or Radiograph Results

Medications/Treatment Schedule

Differential Diagnosis for Referral

To make the process as efficient as possible, please fax or e-mail all current bloodwork, imaging and lab reports relevant to this case in advance of your appointment. Fax (802) 773-0485 or info@rutlandvet.com. If you have any questions please feel free to call us at (802) 773-2779. Thank you.

PRACTICE INFORMATION

Referring Practice *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Referring Veterinarian *

Practice E-mail *

Practice Phone *

PATIENT INFORMATION

Owner's Name *

First

Last

Phone *

Pet's Name *

Birthday/Age *

Species *

Breed *

Gender *

Male
Female

Neutered/Spayed *

Is this pet fractious? *

Is it safe for this pet to receive full sedation? *

Chief Complaints

Current Medications

Medical History

PE Findings

Clinical Diagnostics/Results

Differential Diagnoses/Organs of Interest

Which cavity is to be scanned? *

Abdomen
Cardiac

To make the process as efficient as possible, please fax or e-mail all current bloodwork, imaging, lab reports, and proof of up-to-date Rabies and Distemper vaccines relevant to this case in advance of your appointment. Fax (802) 773-0485 or info@rutlandvet.com. If you have any questions please feel free to call us at (802) 773-2779. Thank you.

PRACTICE INFORMATION

Referring Practice *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Referring Veterinarian *

Practice E-mail *

Practice Phone *

PATIENT INFORMATION

Owner's Name *

First

Last

Phone *

Pet's Name *

Birthday/Age *

Species *

Breed *

Gender *

Male
Female

Neutered/Spayed *

Chief Complaints

Current Medications

Medical History

Is the condition: *

Static
Worsening
Improving

PE Findings

Clinical Diagnostics/Results

Differential Diagnoses

Client ID

Client Name *

First

Last

Phone *

Email *

Patient ID

Patient Name *

Doctor Name *

Information for Owners and Staff:

Please drop off urine samples between 8am and 4pm, Mon - Sat. This is when staff is available to run the tests. The urine should not sit for longer than 2 hours before the tests are run because crystal artifacts may form and render the test inaccurate. This would require checking another fresh sample.

Please put the urine in the refrigerator if you cannot get it to the hospital within 30 minutes of collection.

Questions for Owner:

What date and time was the urine collected? *

Has it been refrigerated? *

Is your pet on any medications? *

If so, what and when was it given?

Why are we testing the urine? *

What are the symptoms?

Accidents in the house
Asking to go out more frequently
Straining to urinate
Blood in urine
Increased thirst
Puddles where your dog has been lying

How long have these symptoms been observed? *

Is this a recheck urinalysis? *

Are symptoms better? *

List any additional symptoms or concerns: *

Where and when can we reach you with results? *

Ready for a visit?

We proudly serve the pets of Rutland and the surrounding communities. We look forward to seeing you and your pet soon. Easily request an appointment for your pet using our online system on PetDesk and keep up with your pet’s health by downloading our app!

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Find Us

90 E Pittsford Rd
Rutland, VT 05701

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Our Hours

Mon – Thurs: 7:00 am – 8:00 pm
Fri: 7:00 am – 7:00 pm
Sat: 7:00 am – 6:00 pm
Sun: Closed

After Hours?

Between the hours of 8 pm – 7 am, please contact Vet Triage, and their veterinary staff will assist owners in finding an appropriate location to take their pets if deemed necessary.

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