Outpatient Orthopedic Surgery Referral

Outpatient Orthopedic Surgery Referral Form

Mahalo for submitting a PAH referral request. Please be aware that submitting a referral request does not guarantee your patient can be seen with us. We are only able to accept referral requests if our schedule has enough availability.

* Indicates required field

Referring veterinary clinic *

referring dvm *

Referring DVM PHONE *

Referring DVM EMAIL *

Is this an existing established mutual client of PAH? *

Client Name *

First

Last

Client Phone *

Client Email *

Patient name *

Patient Species *

Patient Breed *

Patient Age *

patient weight *

Patient Sex *

ORTHOPEDIC CONSULTATION FEE $375
*Orthopedic consultations require patients to be dropped off at PAH to perform sedated radiographs and an exam. Sufficient orthopedic radiographs require calibration and perfect straightness.

ORTHOPEDIC SURGERY REQUEST *

Cruciate / TPLO Traumatic / Fracture

Scheduling urgency *

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

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***

Outpatient Orthopedic Surgery Referral

Outpatient Orthopedic Surgery Referral Form

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