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Veterinary Referrals

Patient Medical Record Request Form

Click here to print and fax the form. Information may be sent by mail, fax, prepaid FedEx mailer or through this web page.

Veterinarian Information:

Name:
Hospital:
Address:
Telephone:
Fax:

Patient Information:

Client name:
Address:
Telephone:
Patient name:
Age:  yrs    Breed:     Sex:  M   MN   F   FS

Your input is very vital in the final decision to proceed with therapy. If the provided information indicates health-related problems that may preclude or complicate therapy, you, the referring veterinarian will be contacted to discuss these issues.

PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION:

Patient medical status form Sending by  Fax     Mail     FedEx Mailer
Copies of (within the last 3 months): SUPERCHEM/CBC, T4, T4 – off Tapazole at least 7 days (if currently on medication) Sending by  Fax     Mail     FedEx Mailer
Urinalysis Sending by  Fax     Mail     FedEx Mailer
Radiographs obtained in the last three months (Chest DV and Lat are required) Sending by  Mail     FedEx Mailer
Copy of any ultrasound reports, if performed (not required) within the last six months: Sending by  Fax     Mail     FedEx Mailer
EKG reports, if performed (not required) within the last six months: Sending by  Fax     Mail     FedEx Mailer
  

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