2060 Niagara Falls Boulevard, Tonawanda, NY 14150
greenacres@buffaloveterinarygroup.com
greenacresveterinarycenter.com
(716) 6940122
Referral form - CT & endoscopy
Check all that apply:
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CT
Endoscopy
In addition to the above procedures, I would like an Internal Medicine Consultation.
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Yes
No
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:
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Yes
No
Chief Complaint/Tentative Diagnosis:
Patient History/Physical Findings:
Procedures/Testing (Please attach results.)
Treatment/Medication (Please attach.)
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)
Other expectation:
Please upload any applicable findings 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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