Transfer Sheet

ATTENTION: PLEASE BE PREPARED FOR LONGER WAIT TIMES.
We are currently experiencing a very high influx in cases needing emergency and critical care attention. Please note that the highest priority cases will be seen first regardless of arrival time. Patients that are more stable may wait several hours before being seen.

Please ensure that you include all of the required information, including a phone number that you can be reached at if necessary.

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Working Diagnosis: *

Does this patient have a zoonotic disease? *

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FLUID THERAPY

	Type	Additives	Rate
1.
2.

MEDICATIONS

	Type	Strength	Amount	Route	Frequency	Last Given	Due Next
1.
2.
3.

SUPPORTING DOCUMENTS

Please upload any supporting documentation such as medical history, x-rays, lab work, etc.

Additional Comments:

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I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Transfer Sheet

Which practice would you like to register with?

FLUID THERAPY

MEDICATIONS

SUPPORTING DOCUMENTS

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