Diagnostic Imaging Referral Form

REFERRING HOSPITAL INFORMATION

Referring Hospital

Phone

rDVM Name

CLIENT INFORMATION

Client Name

Phone

Address

PATIENT INFORMATION

Patient Name

Date of Birth

Sex

Species/Breed

Colour

Weight (kg)

Primary concern and brief history

Medications

ULTRASOUND INFORMATION

How soon does this patient need to be seen?

Urgent Standard

Area to be imaged

If Other, please specify

Does this patient require any additional diagnostics or services?

Radiographs Labwork

Please describe (test name, requested views, etc)

CONFIRMATION CHECKLIST

Please confirm that the following have been completed prior to submitting referral:

Confirmation

Vet to Vet discussion of case Submit recent history Submit recent diagnostic results Submit any estimates provided to the client

REFERRING PRACTICE DECLARATION

By signing below, I confirm that:

The information provided is accurate and complete.
The client has consented to referral to Midtown Veterinary Hospital for diagnostic imaging.
The client understands that the referring veterinarian will review and discuss results with them. The Midtown Veterinary Team will not discuss the case or provide medical advice directly to the client unless emergency circumstances require immediate communication.

Name (Referring Veterinarian)

Signature

By clicking SUBMIT you consent to receiving SMS messages from Midtown Veterinary Hospital. Messages and Data rates may apply. Message frequency will vary. Reply Stop to Opt-out of messaging. Reply Help for Customer Care Contact Information. I have read and acknowledged the Privacy Policy.