Internal Medicine Service Referral Form Internal Medicine Service Referral Form Referring Hospital * Phone * Referring Veterinarian * Practice Email * Owner's Name * Owner's Name First Name First Name Last Name Last Name Email * Phone * Pet's Name * Age/DOB * Weight Species * Breed * Sex * - Select One -FemaleFemale spayedMaleMale neutered List last vaccinations given and dates Current Medications (Dose, Route, Response) Is there anything else we should know? (patient is anxious or aggressive/will bite, past problems with anesthetic drugs, etc.) Precautions/Contraindications Referral Summary pertaining to current problem/diagnosis Please provide a short chronological case summary relevant to the reason for referral (e.g. onset of problem, summary of diagnostic testing done, summary of treatments/medications attempted and response to treatment, list of any therapeutic diets tried) Please indicate past relevant medical history (e.g. previous splenectomy, history of IMHA, history of chronic urinary tract infections, history of B. burgdorfen titers, etc.) Please attach copies of all recent or historical diagnostic testing performed (blood work results, cytology or histopathology reports, past imaging reports) relevant to the reason for referral. Digital radiographs can be uploaded as an attachment. Although you are welcome to attach a copy of the patient’s medical record to the submission, it is not an effective substitution for providing case summary information. This pet has.... Bloodwork and test results/reports Urine test results/reports Radiology Report Ultrasound Report CT Report MRI Report Cytology Report Histopathology Report Please upload any results/reports for items selected above, as well as any additional files you may have Drop a file here or click to upload Choose File Maximum file size: 52.43MB Submit If you are human, leave this field blank.
