Outpatient Orthopedic Surgery Referral

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Outpatient Orthopedic Surgery Referral

Outpatient Orthopedic Surgery Referral Form

* Indicates required field

Referring veterinary clinic *

referring dvm *

Referring DVM PHONE *

Referring DVM EMAIL *

We will send the ultrasound diagnostic report to this email

Client Name *

First

Last

Client Phone *

Client Email *

Patient name *

Patient Species *

Patient Breed *

Patient Age *

Patient Sex *

ORTHOPEDIC SURGERY REQUEST *

Cruciate / TPLO Traumatic / Fracture

Referral Request Expectation *

Consultation ONLY $55 *DVM to review radiographs taken by your clinic. Your radiographs may not be sufficient for a diagnosis or surgical plan. In this case, the next step would be option two and the original consultation fee is non-refundable. In-person consultation with sedated radiographs at PAH $375. *Preferred. Radiographs must be performed under sedation, with calibration and perfect straightness required.

Scheduling urgency *

Emergency (1-7 days) *emergency fee may be applied Non-urgent (7-30 days)

An emergency fee may be applied based on how busy our existing schedule is. If we are squeezing in an urgent ultrasound referral into a completely booked schedule, the emergency fee can range from $70-$150

Brief relevant clinical history and reason for referral *

Specify patient's current medication and any drug allergies (if applicable) *

Upload relevant medical records *

Max file size: 20MB

Upload additional recent radiographs and diagnostics (within 30 days) *

Max file size: 20MB

Client was made aware to fast patient of food for 12 hours prior to appointment *

Yes No

Client is aware that PAH consultation, sedation, radiographs and any additional fees must be paid at time of service *

Yes No

Submit

***Relevant medical records (include full DVM notes) and relevant diagnostics are REQUIRED. PAH will NOT review referral requests without these submitted***

Find us!

15-2714 Pahoa Village Rd. Unit C3.
Pahoa, Hawaii 96778
Office: 808.930.5888
Fax: 808.930.5889
pahoaanimalhospital@gmail.com

Covid-19 Policy

Hours of Operation:

Monday 8:00 am - 5:00 pm
Tuesday 8:00 am - 5:00 pm
Wednesday 8:00 am - 5:00 pm
Thursday 8:00 am - 5:00 pm
Friday 8:00 am - 5:00 pm
Saturday - Closed
Sunday - Closed