Ophthalmology Referral Form

*Required

Referring Veterinarian Information

How would you prefer to be contacted about this case?PhoneFaxEmail

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


Please attach any documents or images related to this case below.
You may also fax any information to 203-867-5195