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Case History
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Referring Veterinarian Information
Veterinarian's Name
Clinic Email Address
Clinic Name
Clinic Phone Number
Patient Name
Patient First Name
Patient Last Name
Procedure Information
Service(s) Requested
Ultrasound
Ultrasound with IMÂ consult
Endoscopy
IM consult without imaging
Urgency
Non-urgent
Semi-urgent
Urgent
Other procedures needed
Cystocentesis
Fine needle aspiration
* Describe aspirate site...
Additional Information
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