Referring Veterinarian Form

Thank you for selecting MEAC to provide urgent care for your patients. We value your confidence in us and look forward to partnering with you to deliver the highest quality care for your patients. Below is our referral form. We prefer that referral forms be completed prior to the appointment. For your convenience we also have a PDF version that can be completed, printed, and either emailed, faxed, or sent with the patient.

This form may be faxed or sent directly with clients. Remember to send copies of test results. Veterinarians please call MEAC to speak directly to the veterinarian who will be caring for your patient (706-632-7879).

Please email or fax additional medical notes.

Download PDF

Referring Veterinarian:(Required)

Date:(Required)

Referring Clinic:

Referring Veterinarian Phone #:

Client Name:(Required)

Client Phone #

Pet Name:(Required)

Species/Breed:(Required)

Sex:(Required)

Altered:

Age:

Vaccines:(Required)

HW Prevention/ Other Medications:(Required)

History / PE:(Required)

Lab Results

PCV/ TS:

BG:

PT:

PTT:

HW:

FELV:

FIV:

CPL:

Parvo:

Fecal:

UA:

CBC:

Chemistry:

Radiology:

FLUIDS

Type:

Route:

Rate:

ml/hr

Additives:

Amount administered by RDVM:

Other:

Medications:

Medications

Medication:

Quantity (mg):

*Method of Administration:

Last Given:

* IV, IM, SQ, PO, SID, BID, TID, QID

Additional Treatment Plan/ Notes:

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