Thrive Pet Healthcare Specialists Albuquerque Patient Referral Form
Preferred Date
*
Next available
This week
Emergency (today/tomorrow)
Patient is on the way
For This Case
*
Consultation only. Please return to my office for diagnostics and treatment.
Please manage the diagnostics and treatment at Thrive Pet Healthcare Specialists Albuquerque .
Referring Veterinarian
*
Hospital
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Method
*
Phone
Fax
Email
Client Information
Client Name
*
First Name
Last Name
Client Email
example@example.com
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Information
Patient Name
*
Type
*
Canine
Feline
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
Breed
*
Color
Weight
DOB
-
Month
-
Day
Year
Date
Service
*
Critical Care / Emergency
Neurology
Internal Medicine
Outpatient Imaging
History (will be provided to a radiologist)
Areas to be imaged
*
Head/skull
Neck/Thyroid/Larynx
Right Elbow
Left Elbow
Right Shoulder
Left Shoulder
Right Stifle
Left Stifle
Right Carpus/manus
Left Carpus/manus
Right Tarsus/manus
Left Tarsus/manus
Pelvis
Thorax
Abdomen
Contrast Requested (recommended for suspected neoplasia)
*
Yes
No
I acknowledge that minimum pre-anesthetic blood work (PCV/TP, electrolytes, blood glucose, BUN or creatinine) had been performed and the results reviewed with the client. We recommend a full CBC and chemistry analysis no greater than 60 days prior to anesthesia. However, the lab tests performed and duration of time between testing and anesthesia is left to the discretion of the requesting veterinarian caring for the patient based upon their knowledge of the patient's medical status, comorbidities, and anesthetic risk.
*
I agree
I acknowledge that the risks of general anesthesia and IV contrast administration have been reviewed with the client prior to imaging.
*
I agree
I acknowledge that I will receive a copy of the radiology report once complete (generally 7-10 days after imaging) and I am responsible for reviewing the results with the clients and making recommendations.
*
I agree
Please check this box if you would like a copy of the images sent to your clinic.
Medical Records
*
Yes
No
Sent with client
Emailed
Faxed
Radiographs
*
Yes
No
Sent with client
Emailed
Faxed
Advanced Imaging US/CT/MRI/Echo/ETC
Lab Results
*
Yes
No
Sent with client
Emailed
Faxed
Reason For Referral
*
Previous/Current Treatment or Medication
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