Endoscopy Referral Form

Referring Clinic Information

Clinic Name
Date
Referring Veterinarian
Clinic Email
Clinic Phone

Client Information

Name
Contact
Email

Patient Information

Name
Species
Breed
Sex
Date of Birth
Weight
Microchip

Appointment Request

Date
Time
The patient will come with

Patient History

Please give a brief overview of your medical history, diagnosis, chronic conditions, anesthetic reaction, known allergic reaction, and sensitivities.
Medications (List all of current medications and dosages, and mention any dietary restrictions)
Latest Biochemistry and CBC Results
Please take note that results must be received no later than two days before the planned scan date (Mandatory for Anaesthesia)
Has the patient undergone a Endoscopy before?

Any Queries to be Addressed

Specific Endoscopic Procedure Request

Please check the relevant procedure and specify if required

Reporting Images

Reporting will be done 48 hours after the procedure.
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If you would like to schedule an appointment, please don’t hesitate to reach out to us.

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About us
We pride ourselves on delivering top-tier veterinary care in a welcoming, modern environment. Since 2012, our experienced team has served countless pets across the UAE with compassion and expertise.
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For more information
800 3990
Location
Al Wasl Road, Corner Al Manara, Villa No. 881, Dubai
Email
info@thecityvetclinic.com
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