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Referral Form
VSCD New Castle ● 290 Churchmans Road ● New Castle, DE 19720
VSCD Dover ● 1482 E Lebanon Road ● Dover, DE 19901
ONCOLOGY
ANESTHESIA & ACUPUNCTURE
RACHAEL GAETA, DVM, DACVIM
LAURIE SORRELL-RASCHI,
DVM, DACVA, RRT
OPHTHALMOLOGY
CARDIOLOGY
JEFFREY BOWERSOX, DVM, DACVO
KATHRYN WOTMAN, DVM, DACVIM, DACVO
MICHAEL MILLER, VMD, DABVP,
Practice Limited to Cardiology
CRITICAL CARE
DATE:
_________________
(P) 302.322.6933
(F) 302.322.6883
[email protected]
REHABILITATION & HYDROTHERAPY
WWW.VSCDEL.COM
REID GROMAN, DVM, DACVIM, DACVECC
NATALIE CAMPBELL, VMD, CCRP
DAVID MAZZONI, CMT, HYDROTHERAPIST
DENTISTRY & ORAL SURGERY
ULTRASOUND/RADIOLOGY/CT
EMERGENCY – 24/7
VAN W. KNOX IV, VMD, DACVR
YAEL PORAT-MOSENCO, DVM, DECVDI, DACVR
JEFFREY BARNET, DVM
ELIZABETH BUKOWSKI, DVM
MASHA (RUBIN) McCARTHY, DVM
MICHELLE McCLAIN, DVM
LAURA PELL, VMD
KELLY SAVERINO, DVM
PAUL ORSINI, DVM, DACVS, DAVDC
INTERNAL MEDICINE
JEREMY DIROFF, DVM, DACVIM
CARRIE GOLDKAMP, VMD, DACVIM
ERIC WALSH, DVM
SURGERY
MARK COFONE, VMD, DACVS
ART JANKOWSKI, VMD, DACVS
SCOTT ROBERTS, VMD, DACVS
Practice Limited to Internal Medicine
REFERRAL INFORMATION
REFERRED TO VSCD SERVICE/DR:
REFERRED BY DOCTOR:
Hospital Name:
Phone (
Email Address:
)
Fax (
Our hospital prefers follow-up by:
 FAX
@
)
 EMAIL
 PHONE
 MAIL
CLIENT INFORMATION
OWNER NAME (first & last)
Been to VSCD before?
Phone:
 NO
 YES
(
)
PATIENT NAME
Species
Dog
●
Cat
Sex:
Breed:
ETA:
Age:
Male ● Female
Status:
Yrs:
Neutered
●
Weight:
Mo:
Spayed
Lbs ● Kg
PATIENT HISTORY
DIFFERENTIALS OR REASON FOR REFERRAL
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
PERTINENT HISTORY (please attach records pertinent to this condition)________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
______________________________________________________________________________________________________________
TREATMENTS ALREADY ADMINISTERED (use second sheet if necessary)
Drug/Dose
Time/Date
DIAGNOSTICS ALREADY PERFORMED & ENCLOSED
Drug/Dose
 Bloodwork
Time/Date
 Radiographs
Drug/Dose
 Other Imaging
Time/Date
 Lab Reports
VACCINATION RECORD (note date for each) Rabies ____________ Distemper ____________ Lyme ____________ Parvo _____________ FVRCP____________ Felv/FIP___________
CARDIAC HISTORY/ALLERGIES/CHEMOTHERAPY (Pre-existing conditions? Please note last date chemotherapy was administered.)
 NO
 YES (list)________________________________________________________________________________________________________________________________________
If an emergency case, would you like this patient returned to you the following business day?
 NO
 YES
SPECIAL REQUESTS __________________________________________________________________________________________________________________________________________01/14