Doctor Referral Form

Internal Medicine Specialist - Referral Form
An Internal Medicine Consult - You are referring the case to Dr. Lawren. Dr. Lawren will see the patient and share the findings directly with the patient and will provide you with a written report. We will invoice the client direct.

A Doctor-to-Doctor Consult - this is a case review of your existing notes. Dr. Lawren will review your notes and test results and provide an opinion for you to discuss with your patient. We will invoice your clinic, and you will invoice your client.
Referral Type

Internal Medicine ConsultDoctor-to-Doctor Case Review (bill to clinic)Outpatient UltrasoundOther
Is the patient currently hospitalized?

YesNo
Referral Type

Internal Medicine ConsultDoctor to Doctor Consult(Bill to clinic)Outpatient UltrasoundOther
Referring Clinic Information
Referring Veterinary Clinic*
Referring Veterinarian*
Referring Clinic or Doctor Email*
example@example.com
Referring Clinic Phone Number*
Please enter a valid phone number.
Patient Information
Patient's Name*
Patient Species and Breed*
Patient Sex*

MaleFemaleunknown
Neutered / Spayed*

YesNounknown
Patient Age or Date of Birth
Owners Information
Prefix*
First Name*
Last Name*
Owners Email*
example@example.com
Owners Phone Number*
Please enter a valid phone number.
Medical Notes
Reason for Referral*
Diagnostics Performed to Date (briefly describe)
Current Treatments and Medications
Questions To Be Addressed
Other Important Information
Patient History

Please attach any patient history files, or email history to info@hkvsi.com
Patient History

Cancelof
Imaging (X-rays, CT Scans,

Cancelof
Lab Tests and Bloodwork

Cancelof
Should be Empty:

Internal Medicine Specialist - Referral Form

Referring Clinic Information

Patient Information

Owners Information

Medical Notes

Patient History