Rehabilitation - Tier 1 Veterinary Medical Center

Referring Hospital*

Date

Referring Veterinarian*

Client Name*

Phone Number*

Email*

Patient Name*

Breed*

Age

Sex*

Weight (kgs)

Clinical Condition

Onset/Sx Date

Current Medications/Dosing Intervals

Special Instructions/Considerations/Comorbidities

Frequency/Duration

Times per week

for

weeks

Plan (Check All That Apply):

Other

DVM Signature

Please attach diagnostic results (bloodwork, CT/MRI, radiographs etc) and pertinent medical history with submission e-mailed to info@tier1vet.com

I understand that proof of rabies vx and negative fecal/giardia (within 30 days) will be required?

Name

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6623 East Blue Lupine Rd, Palmer, AK 99645