Name: Long Animal Hospital & Emergency Center
Address: South Boulevard, Charlotte, NC, 28203, US
Telephone: (704) 523-2996
Price range: $$

Patient Transfer Questionnaire

-Please request all medical records be sent, and fill form out complete.

-Once completed take form back to the triage tech.

rDVM Clinic
Veterinarian
Email/Fax for Discharges
Clinic Name
Phone Number
Patient Name
Species
- Dog
- Cat
Age
Sex
- M
- F
Weight
Breed
Presenting Complaint
Pertinant History
Diagnosis
Medications Given & Time
Is the patient stable or critical
IV catheter
- Yes
- No
Fluids
- Yes
- No
ETA
Estimate Given?
Upload Records
Drop files here or
Please be sure to upload any relevant records. If you do not upload your records please bring them in person.