Referral Form in Scottsdale, AZ

This information must be available at the time of service or we may need to reschedule the appointment. Thank you for your referral.

DVM Information

Referring doctor

Hospital name*

Email*

Hospital Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Fax

Best time to call

Preferred method of contact

phone
fax
e-mail

Service location

Mobile
In Hospital at Salt River

Patient Information

Owner*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Pet's Name*

Species

Canine
Feline

Breed(s)

Age

Color

Weight

Current on vaccines

Yes
No

Spayed/Neutered

yes
no

Sex

Presenting problem

History/Pertinent Physical Findings/Treatment

Condition of patient

Healthy
Stable
Critical

Examination Request

Ultrasound only
Internal Med Consult
Surgery Consult

Ultrasound location

Abdominal
Thoracic
Bi-cavitary
Neck

Reason for ultrasound

Additional Requests

Fine needle aspirate
Fluid sample
Cystocentsis

(If indicated by ultrasound, please select any of the procedures to the right that you would like performed. Some of these procedures may require sedation or anesthesia.)

Client Communication

All clinical findings and images will be provided to the referring veterinarian following the examination. For ultrasounds only, the referring veterinarian is responsible for informing the client of the findings.

I have reviewed and completed this form submission to Salt River Veterinary Specialists for the evaluation of my patient.*