Overnight/Weekend Monitoring Transfer FormPlease fill in the form below and submit or if your prefer to fill in a hardcopy please download, print and email a copy to: info@emergencyvethospital.co.nz DOWNLOAD HARDCOPY Please make sure you also phone ahead: 0800 EVH 111 OWNER NAME * First Name Last Name OWNER Email * OWNER Phone * PATIENT NAME * PATIENT Species/Breed PATIENT Age PATIENT Weight Clinical notes/Diagnostics * With Owner Emailed to EVH TRANSFERRED FROM * CLINIC NAME Transferring Veterinarian Name Transferring Vet Contact Phone Number (s) Latest Time To Call Transferring Vet If treatment plan requires modification, call transferring Veterinarian? * Yes No PLEASE NOTE: an After-Hours Transfer Consult Fee of $220 is due for payment in full at time of the consult. Further estimated costs will be discussed at time of the consult. A 50% deposit based on this estimate will be required. The final settlement is due in full upon discharge/collection of your pet. Owner Informed * YES NO TRANSFERRED FOR * DIFFERENTIAL DIAGNOSIS REQUIRED CARE: eg post-op care, further medical workup, surgery etc DISCHARGE/TREATMENT PLAN FOR NEXT DAY: FLUIDS Provided * YES NO FLUID Type FLUID Rate (ml/hr): DRUG 1 ADMINISTERED * DRUG NAME DRUG 1 Dose Given DRUG 1 Amount DRUG 1 Route (IV/IM/SQ/PO) DRUG 1 Date/Time Last Given DRUG 1 Frequency Prescribed DRUG 2 ADMINISTERED DRUG NAME DRUG 2 Dose Given DRUG 2 Amount DRUG 2 Route (IV/IM/SQ/PO) DRUG 2 Date/Time Last Given DATE/TIME LAST GIVEN DRUG 2 Frequency Prescribed DRUG 3 ADMINISTERED DRUG NAME DRUG 3 Dose Given DRUG 3 Amount DRUG 3 Route (IV/IM/SQ/PO) DRUG 3 Date/Time Last Given DRUG 3 Frequency Prescribed BRIEF HISTORY PERMISSION TO DISCHARGE (if well) or transfer back to your care if your patient needs ongoing hospitalisation tomorrow morning/after the weekend: * YES NO PLEASE ENSURE YOUR PHONE AHEAD BEFORE YOU SEND: 0800 EVH 111 Thank you!
