Transfer Form

For patients that are being transferred to EMAEC

Form should be completed by transferring hospital or veterinarian.

Form can be completed on paper or online:

Download Form: complete and fax to (678) 212-0301, or send completed form with client.
Download Form
Onine: complete form below and click submit

Referring Veterinarian or Clinic

Date

Client Name (first & last)

Pet Name

Pet's Age

Species

Sex

Male

Female

Spay or Neutered?

Spayed

Neutered

Weight

Differential Diagnosis (or differential list)

Brief History or Problem

Pre-existing Problems (blindness, chronic lameness, DM, etc)

Lab Results: FELV/FIV

Lab Results: HW

Type

Route

Rate

Volume Infused

Additives

Laboratory test you would like performed?

Additional info, history, or notes

I (doctor) would like to be called at home in the event any of the following occur:

Phone number (only if you would like to be called if above mentioned occurs)