Patient Referral Form

FOR REFERRING VETERINARIANS ONLY. Pet parents, please call our hospital directly to make an appointment with one of our doctors.
Patient Referral Form
Referring Veterinarian Information
Referring Veterinary Clinic*
Referring Doctor Name*
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Email*
example@example.com
Are you requesting a specific doctor? (Please note: Specific doctor requests are not available for Radiology or Outpatient Imaging.)*

No. First available appt.Yes. Specific Doctor
Name of Doctor Requested
**You cannot request a specific doctor for Radiology or Outpatient Imaging
I understand that my client will need to call Central Hospital to book their appointment. This form is for submitting referral requests and records for the specialist. This form does not create an appointment.*

I understand
Department you are referring to:*

Anesthesia/Pain Mng.BehaviorCardiologyHyperbaric O2 TherapyI-131 TherapyInternal MedicineNeurologyOncologyOphthalmologyRadiology & Outpatient ImagingSports Medicine & Rehab (acupuncture)Surgery
Patient Information
Pet/Patient Name*
DOB*

MonthDayYear
Date
Species*

DogCatAvian/Exotic
Breed*
Gender*

MaleFemaleMale NeuteredFemale Spayed
Client Information
Owner's Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Referral Information - Ophtho
Eyes Involved?*

OSODOU
Tentative Diagnosis*
Current Medications*
If patient has diabetes, is it well controlled

N/ANoYes
Referral Information - Anesthesia, Sports Medicine & Rehab
Anxiety Level*

12345
Pain Level*

12345
Medications (Name, Amount, How often)*
Referral Information - Cardiology
Reason for referral (include relevant history, clinical findings, images)*
Date of last Chest Rad

MonthDayYear
Date
Date of last Blood Work

MonthDayYear
Date
Date of last Echo

MonthDayYear
Date
Medications (Name, Amount, How often)*
Referral Information - Neurology
Referral Information - Surgery
Referral Information - Internal Medicine
This form is for Internal Medicine referrals only. If you are trying to refer a patient for outpatient ultrasound imaging, please fill out the radiology form.

I undertand
Reason for referral (include relevant history, clinical findings, images)*
Referral Information - Oncology
As the referring doctor, I agree to fill out each section of this form. Please note that "see medical notes" or "medical notes emailed/sent" will not be accepted. Please input all clinical findings in the following sections.*

I agree
Reason for referral (include relevant history, clinical findings, images)*
Diagnosis*
Medical Treatments and current medications/supplements*
List any tests performed and any radiographs that are attached*
Pending tests
Laboratory for pending tests
Referral Information - Radiology

Thank you for your interest in sending us this case for ultrasound imaging. For the most thorough evaluation possible, we ask that you complete the following information in the patient’s clinical history section
I understand that I, the primary care veterinarian, will provide the client with all results when finalized by Central Hospital.*

I understand and agree
We do not offer outpatient CT scans. Cases requiring CT will need to be referred to the appropriate specialty service based on the patient’s underlying condition.*

I understand.
Complete patient signalment*
Indications for the examination*
Concise history with a summary of supporting clinical and physical examination findings*
A list of tentative clinical differential diagnosis*
Tests to be performed
Ultrasound

AbdomenNon-cardiac thoraxNeckOther
If Other, please explain
Radiography/contrast procedure
Describe VD, lateral, etc.
Comments
I agree to inform the owner of these notes and agree to the following (please check all to agree to each term)*

Food should be withheld for 12-15 hours prior to the procedure for optimal image quality and in the case that sedation/anesthesia is requiredFor ultrasonographic procedures, the area of interest will be shaved to optimize image quality and maximize the diagnostic potential of the testOwners will not be given the results of the imaging procedures performed except under certain, critical circumstances.The owners will be asked to contact your office for the imaging results and to make plans for further actions. This is to keep you in control of your case and to simplify communications. If you would like a member of the radiology team to go over the results please call the imaging department to set up the appropriate consultation.Biopsies, needle aspirates, and other interventional procedures are not scheduled as outpatient procedures and cannot be performed as an add-on to an outpatient exam except in critical cases where the case is transferred to a staff doctor for case management. Non-emergent procedures can be scheduled through the imaging department as day-admits.
Referral Information - I-131 Therapy
Additional notes about I-131 (mark each to agree)*

CBC, chemistry panel and urinalysis at least one month prior to treatmentComplete medical record from the time of diagnosis of hyperthyroidism, including pretreatment T4 valueIf the patient is on methimazole (Tapazole or Felimazole) or other anti-thyroid medications, the owners should stop giving medications at least 5-7 days prior to the time of treatment.If a heart murmur, arrhythmia, tachycardia or signs of respiratory disease are present, a chest x-ray and/or echocardiogram are requiredWe may repeat a serum T4 level on or close to the day of treatment
Does the patient have any concurrent underlying medical condition(s)?*
Has the patient been treated with methimazole (Tapazole or Felimazole)?*

YesNo
If Yes, dosage?
Any adverse reactions to the drug?
Has blood work been rechecked since starting the drug?
What was the T4 level when diagnosed with hyperthyroidism- PRIOR to starting methimazole?
Has the patient been treated with Hill’s Y/D prescription diet?

YesNoUnsure
Is the patient on any other medications? If so, doses?
Past pertinent history?
Dr. Harley can work with you to help perform any of the necessary pre-treatment work up (if you prefer) and can help answer any additional questions about referral or treatment. Cases will always be referred back to you once the cat has been evaluated and treated at Central, although it is recommended that cats return to our facility for any medical issues that develop during the radioactive period (first 3 weeks after release).
Referral Information - Behavior
Please describe the behavior for which you are referring this patient. *
Please list any diagnostics that have been performed to work up this behavior and share a general summary of the results of those diagnostics. *
Please list any medications (including doses and when the medication was started, if known), supplements, or other treatments performed for this behavior.*
Please indicate whether or not this patient has exhibited aggressive behavior (growling, barking, snapping, biting) towards you, your staff, or other animals in the vet clinic and in what context these behaviors occurred (i.e. when you enter the room, during restraint, etc)*
Please attach: relevant patient records, images, or diagnostic results

Cancelof
Please verify that you are human*
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Patient Referral Form

Referring Veterinarian Information

Patient Information

Client Information

Referral Information - Ophtho

Referral Information - Anesthesia, Sports Medicine & Rehab

Referral Information - Cardiology

Referral Information - Neurology

Referral Information - Surgery

Referral Information - Internal Medicine

Referral Information - Oncology

Referral Information - Radiology

Tests to be performed

Referral Information - I-131 Therapy

Referral Information - Behavior