Patient is to be referred to Dr. or Dr. Owner: PhoneAddress: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 AppropriateReferring Doctor: Hospital Name: Date MM slash DD slash YYYY PhoneFax 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.
