REFERRAL FORM

  

C.H. "Skip" Tangner,
DVM, MS
Diplomate American College of Veterinary Surgeons

Veterinary Surgery Center
13551 N. Indiana | OKC, OK 73134
(405) 751-3920 1-800-762-2962
Fax (405) 755-7927

Susan Streeter
DVM
 Diplomate American
College of Veterinary
Surgeons

http://www.veterinarysurgerycenter.com

Pet Owner Information:
Name:_________________________
Address: _______________________
______________________________
_____________Zip_______________
Phone: Home ___________________
Business _______________________
Patient's Name: __________________
Breed: _________________________
Age:__________Sex: ____________

Referring Veterinarian:
Name: __________________________
Address: ________________________
_______________________________
_______________________________
_______________Zip _____________
Phone: (     )______________________
FAX: (     )_______________________
E-mail: (    ) ______________________
 

History/Problem:____________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Recent Treatment & Medications:_____________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________
 

****PLEASE BRING:
1. Current medications    2.  This referral form
 NO FOOD OR WATER AFTER  9:00 P.M. the evening  before the appointment
Appointment: Day - ____________________ Time - ___________________

Our FAX number:  (405) 755-7927  Back to main section