REFERRAL REQUEST (Bellingham)

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

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-758-2200 | FAX: 1-888-867-6928 | bellingham@bbvsh.com
Reason for referral:*

Specialty Consultation (choose from list below)Emergency ConsultationImaging via Specialty Department (choose from list below)
Refer to (select all applicable):*

Internal MedicineOncologySurgeryRehabilitationCardiology
Imaging requested (select all applicable):*

UltrasoundEchocardiogramCT
Imaging requested (select all applicable):*

UltrasoundEchocardiogramCTNone
Urgency of referral:*

Same-day (i.e. direct transfer to specialist)Urgent (typically 1-3 days)Next available elective appointment (e.g. typically 1-2 weeks)
Urgency of referral:*

Urgent (typically 1-3 days)Urgent - Direct transfer same day (please call to confirm availability)
Please call and speak to a specialist (if available) for direct transfer.
Referring Veterinarian
Referring Veterinarian
Referring Hospital*
Daytime Phone Number*
FAX Number
After Hours Phone Number
Clinic email address*
Preferred Method of Contact*

PhoneFaxEmail
Client Information
Name*

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

FMFSMN
Age*

MonthDayYear
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.*
Please send medical records, including results, reports, and images (DICOM preferred).
Relevant Medical Records arriving by:*

Emailed to bellingham@bbvsh.com (preferred)Uploaded to this formFaxed to 1-888-867-6928Sent with Owner
File Upload
Click below to upload any supporting document or Radiographs. Please submit high resolution Radiographs. 10MB max file size per file

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

Email: bellingham@bbvsh.com Phone: 360-758-2200

Fax: 1-888-867-6928
Should be Empty:

Referral Request

Please call and speak to a specialist (if available) for direct transfer.

Referring Veterinarian

Client Information

Patient Information

Reason For Referral

Please send medical records, including results, reports, and images (DICOM preferred).