REFERRAL REQUEST (Bellingham)

Referral Request (Bellingham)

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

Surgery Oncology Outpatient CT
Type of referral *

Urgent Next Available
Referring Veterinarian
Referring Veterinarian
Referring Hospital *
Daytime Phone Number *

Area Code Phone Number
FAX Number

Area Code Phone Number
After Hours Phone Number

Area Code Phone Number
Clinic email address
Preferred Method of Contact

Phone Fax Email
Client Information
Name *

First Name Last Name
Home Phone *

Area Code Phone Number
Mobile Phone

Area Code Phone Number
Street Address
City
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
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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 (Bellingham)