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
