DVOS - Referral form

Referring veterinarian:

Practice Name:

Tel:

Email:

Owners details:

Surname:

Initials:

Title:

Patient details:

Name:

Breed:

Age:

Sex:

Color:

Weight:

Please attach relevant photo(s) and documentation:

Select all photos/files to attach and upload simultaneously

Clinical information:

History:

Menace response:

Palpebral reflex:

Corneal reflex:

Dazzle reflex:

OD:

OS:

OD:

OS:

OD:

OS:

OD:

OS:

Direct pupillary light reflex:

Consensual pupillary light reflex:

OD:

OS:

OD:

OS:

Fluorescein stain:

Intra ocular pressure:

OD:

OS:

OD:

OS:

OD = right eye; OS = left eye

Electronic Fund Transfer [EFT]

Banking details:

Standardbank

Account name: DIGITAL VETERINARY OPTHALMOLOGY (PTY) LTD

Account type: CURRENT

Account number: 10 13 391 472 9

Please use practice name as reference

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