Ophthalmology Referral Request

Please use the below form to request an Ophthalmology Referral with Dr Petra Price, Veterinary Specialist in Ophthalmology.

To assist us in triaging the referral effectively, please include images with your submission.

See HERE for further information about our ophthalmic services.

For further inquiries email: referrals@tvg.co.nz

Referring Veterinarian

Clinic

Phone

Name

First

Last

Phone

Address

Address Line 1

City

State / Province / Region

Postal Code

Patient Name

Species

Breed

Age

Is this case an emergency?

Please summarise the eye problem

Please note this summary will appear in the referral report provided to clinic and client.

Pet insured

Does the patient have any systemic health concerns or blood work abnormalities? If so please sumarise.

Please list all medications used for the eye problem

Please list all other medications

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Please upload the patients clinical notes and any additional information. Accepted file types: PDF, DOC, DOCX, JPG, JPEG, PNG, .xlsx.

Attention