2060 Niagara Falls Boulevard, Tonawanda, NY 14150
greenacres@buffaloveterinarygroup.com
greenacresveterinarycenter.com
(716) 6940122
Referral form - Internal Medicine
We now use RVetLink for all referrals!
Please visit our website, call 716-694-0122 for more information, or copy and paste the following link to access our portal: https://buffalovet.rvetlink.com/Account/Login?ReturnUrl=%2FChart
Check all that apply:
*
CT
Endoscopy
Ultrasound
Echocardiogram
Expectation for this case?
*
Consult, Diagnostic Testing, and Treatment
Ultrasound: please transfer patient back to my practice for treatment after imaging
Consult Only, No additional diagnostics
Other (Please Specify Below)
Specific Requests (i.e. internal medicine consult only, etc.)
Referring Provider/Facility Information
Doctor:
*
First Name
Last Name
Facility:
*
Phone Number
*
E-mail
*
example@example.com
Client Information:
Name:
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Patient Information:
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Species:
*
Canine
Feline
Other
Sex:
*
Male
Female
Spayed/Neutered:
*
Yes
No
Chief Complaint/Tentative Diagnosis:
Patient History/Physical Findings:
Procedures/Testing (Please attach results.)
Treatment/Medication (Please attach.)
Other expectation:
Please upload any applicable documents here.
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I understand that a current medication list and all relevant procedures and test results (including radiographs) must accompany the patient to the appointment. This information is necessary for the doctor to provide the most comprehensive care.
Yes
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