REFERRAL REQUEST (Bellingham)

Referral Request

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

Pet OwnerReferring Veterinarian
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 3-5 days)Next available elective appointment (e.g. typically 1-3 weeks)
Urgency of referral:*

Urgent (typically 3-5 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).