Referral Summary

You or your veterinarian may use this form to summarize information prior to your pet's appointment. You may bring it with you to your appointment, or your vet may fax it to 707.449.8468, or mail it to Animal Ophthalmology Services, 825 Davis Street, Suite A, Vacaville, California 95687.


Client Name:

Patient Name:

Patient Breed, Age and Sex:

Referring Veterinarian (Name, Phone and Fax):

Referring Veterinary Hospital Name:

Reason(s) for Referral and Special Concerns:


Diagnostic Tests and Dates Performed (Please attach a copy of blood test results):

Medication(s) Used, Routes of Administration and Dates Administered: