Vet Referral for Laparoscopic Procedure

This form is for veterinarian use ONLY.

Referring Clinic & DVM *

Layout

Clinic Phone Number *

Clinic Email *

PATIENT INFORMATION

Patient's Name *

Gender *FemaleFemale, SpayedMaleMale, Neutered

Date of Birth *

DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Layout

Rabies Vaccine Due Date *

DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

DHPP Vaccine Due Date

DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Kennel Cough Vaccine Due Date

DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

What medications/supplements is the patient currently taking? *

Does the patient have any concurrent health conditions? *

CLIENT INFORMATION

Primary Owner *

First

Last

Secondary Owner

First

Last

(with authority to make medical decisions)

Client Phone Number *

Client Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Layout

Has the client read and signed the surgery consent/cost-annotated treatment form? *

• Yes

Has the client reviewed the provided documents regarding laparoscopic procedures? *

• Yes

Have you reviewed the "Important Information for Laparoscopic Surgery Procedures" included at the bottom of this page? *

• Yes

Submit

Important Information for Laparoscopic Surgery Procedures

Please note that all patients presenting to Carling Animal Hospital for any laparoscopic surgery procedure must have a complete blood count and age-appropriate chemistry analysis performed within 10 days of the procedure. Please review this blood work with the client yourself, and forward the results to info@carlinganimalhospital.com at least 48 hours in advance of the surgery date.

Pre-Visit Pharmaceuticals for Dogs:

• Trazodone: Administer 6 mg/kg orally 12 hours and 2 hours prior to admission on the day of the procedure.
• Cerenia: Administer 2 mg/kg orally 2 hours prior to admission on the day of the procedure.

Pre-Visit Pharmaceuticals for Cats:

• Gabapentin: Administer 100 mg orally 12 hours and 2 hours prior to admission on the day of the procedure.
• Cerenia: Administer 1 mg/kg orally 2 hours prior to admission on the day of the procedure.

Please advise your client that they will meet with a DVM for approximately 20-30 minutes on the morning of the procedure to perform a physical examination of the pet and answer any last-minute questions. However, we are available to provide answers to any questions in advance through your team. The patient will be discharged to the client by the end of the day (5:30 pm), and any follow-up care will be handled by your hospital. We are happy to consult on any post-surgical issues, but management of these patients post-surgically should be typical to any other abdominal surgery procedure.

Thank you very much for your referral. We look forward to working with you and your clients.