Ophthalmology Referral Form

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Referring Veterinarian Information




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Client Information




Patient Information


SPECIES: Avian/ExoticCatDogOther

SEX: FFSMMNUnknown

Tentative Diagnosis

Eyes Involved?OSODOU

Current Medications (ocular and systemic)

If dog is diabetic , is diabetes well controlled? N/AYesNo


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