REFERRAL REQUEST (Bellingham)

This referral form is for primary care veterinarians only.
Referral Request

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-982-0166 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Refer to: *

Surgery Oncology CT Cardiology Ultrasound Internal Medicine Rehabilitation
Type of referral *

Urgent Next Available
Referring Veterinarian
Referring Veterinarian
Referring Hospital *
Daytime Phone Number *
FAX Number
After Hours Phone Number
Clinic email address
Preferred Method of Contact

Phone Fax Email
Client Information
Name *

First Name Last Name
Home Phone *
Mobile Phone
Street Address
City
ZIP
Client email address
Patient Information
Patient Name *
Species *
Breed
Patient Sex

F M FS MN
Age *

Month Day Year
Date
Reason For Referral
Current Concern(s) Requiring Referral *
eg. clinical history, PE findings, etc
Diagnostic Tests performed *
eg. lab reports, etc
Current Medications currently or previously given. *
Relevant Medical Records arriving by:

Fax Email Sent with Owner
File Upload
Click below to upload any supporting document or Radiographs. Please submit high resolution Radiographs. 10MB max file size per file

Cancel of
Please Note

Please send all relevant records, lab results and diagnostic images. Once you have sent your referral, please contact our office to confirm receipt.

Phone: 360-982-0166 Fax: 1-888-867-6928
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Referral Request