Referral Form - Queen City Veterinary Internal Medicine

Veterinary Internal Medicine Referral Form

What kind of appointment do you need?

Outpatient Ultrasound (No internal medicine consultation)

Consult (Includes Abdominal ultrasound if indicated)

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Veterinary Practice Name

Name of the veterinary practice referring the patient.

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Referring Veterinarian's Full Name

The full name of the referring veterinarian.

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Referring Vet Email

Email address of the referring veterinarian.

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Referring Vet Phone

Contact number of the referring veterinarian.

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Client Contact Preference

How does the client prefer to be contacted?

Client will call

Client needs to be contacted

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Client First & Last Name

First and last name of the client.

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Client Phone

Phone number of the client.

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Client Email

Email address of the client.

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Patient Name

Name of the patient.

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Breed

Breed of the patient.

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Patient Age

Age of the patient in years or months.

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Sex of Patient

Sex and reproductive status of the patient.

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Approximate Weight

Approximate weight of the patient in lbs or kg.

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Reason for Referral

Please summarize the reason for the referral.

This field is required.

Current Medications

List any current medications the patient is taking.

Veterinary Internal Medicine Referral Form

Please send all pertinent medical records to [email protected]