Types of Referrals

IMPORTANT: We offer three types of referrals through this form. When filling out the referral form below, please select the appropriate referral type.

rDVM-IM Consultation

Internist-to-rDVM consultation. Internist partners with rDVM to communicate and work directly on case management. Consultation includes review of medical records, PE, and procedure(s); followed by verbal and written consultation with rDVM to discuss diagnostic findings, assessment, and recommendations.

The rDVM remains the primary doctor to communicate plan and long-term care with the client. Internist continues to follow-up with rDVM on case management on case-to-case basis as deemed appropriate.
Client-IM Consultation

The more traditional consultation approach of transferring primary care of presenting concern(s) including communications +/- long-term follow-up case management to internist. Internist assumes most of the case management and communication.

If rDVM is interested, internist is happy to collaborate with rDVM, so client and patient can continue follow-up care with primary veterinarian and clinic.
Ultrasound

All ultrasound referrals are coordinated through internal medicine.

Referring Veterinarian *

Referring Clinic *

Referring Clinic Phone *

Referring Clinic or Veterinarian E-mail *

Type of Referral

Choose the type of referral you are submitting *

If you have selected Internist-to-rDVM consultation, please provide the days of the week the rDVM is in clinic to better facilitate relaying results and case communication

Client Information

Name(s) *

Phone Number(s) *

E-mail(s)

Patient Information

Name *

Species *

Dog

Cat

Date of Birth/ Age *

Patient Sex *

Breed *

Medical Information

Presenting Concern *

Preliminary Diagnosis *

Pertinent Medical History: Please include procedure requested. *

Diagnostic Tests *

Treatments: Please include response to therapy if possible. *

Medication or Supplement #1 *

Concentration & Instructions Med #1 *

Medication or Supplement #2

Concentration & Instructions Med #2

Medication or Supplement #3

Concentration & Instructions Med #3

Medication or Supplement #4

Concentration & Instructions Med #4

Diet *

Additional Information or Other Medications:

Please attach all pertinent medical notes (include any available records from previous clinics), original diagnostic test results (e.g., copies of bloodwork, imaging report), and images, if possible, to facilitate your client and patient’s referral.

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Internal Medicine & Ultrasound Referrals

Types of Referrals

Type of Referral

Client Information

Patient Information

Medical Information

New Patients Welcome