Patient Referral Form in San Antonio, TX | Alamo Feline Health Center

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Patient Referral Form

Patient is to be referred to Dr.
or Dr.
Owner:
Phone
Address:
Patient Name:
Sex:
Age:
Species:
Breed:
Colour:
Primary Symptom or Problem:
Pertinent Test Results:
Tentative Diagnosis:
Current or Recent Medications or Treatments:
This case is referred for:
- Diagnostic Workup and Therapy
- Only Diagnostic Workup
- Only Specific Tests*:
- Only Specific Treatment:
* NOTE: We accept referrals for specific tests that you may wish performed. If only specific tests are requested and our doctor does not interact with the client, there will not be an examination charge or full case management letter. Lab reports will be sent directly to you, and you should handle client communication, explanation of reports, and therapy. However, it is your responsibility to request the correct test for the case.
Comments or Requests:
Please Attach or Fax Pertinent History and Tests Results and Send Radiographs if Appropriate
Referring Doctor:
Hospital Name:
Date
MM slash DD slash YYYY
Phone
Fax
To The Client: In order to avoid duplication of work and expense, please bring radiographs and copies of the records unless they have been sent or faxed previously.

Alamo Feline Health Center