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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