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TACC New York · Referral Form
Referring Veterinarian Information
Doctor’s Name
Hospital Name
Phone Number
Fax Number
Email Address
How do you prefer to be contacted about this case?
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Phone
Email
Owner Information
Full Name (First and Last)
Phone Number
Alternate Phone Number (Optional)
Email Address
Pet Information
Pet’s Name
Pet Age
Species
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Canine
Feline
Exotic/Pocket Pet
Breed (Please write N/A if unsure)
Gender
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Male (not neutered)
Male (neutered)
Female (not spayed)
Female (spayed)
Unknown
Are you planning to prescribe this patient corticosteriods?
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Yes
No
Reason for referral
List of comorbidities
Current Medications
Is the patient scheduled to have anesthesia? if yes, when?
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Thank you!
Our team will be reaching out to you shortly. In the meantime if you have questions, please reach out to info@taccvets.com!
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