• Reasons for Referral
  
  

20610 N. Cave Creek Road
Phoenix, AZ 85024

VETMED phone: (602) 697-4694
Fax: (602) 992-3755

Appointments Available:
Monday - Friday, 8 a.m. to 6 p.m.

Receptionist Available:
Monday - Friday, beginning at 7 a.m.
Saturday 8:30 a.m. to 12:30 p.m.

Referral Form

The following form is to be completed by referring veterinary offices.

Appointment Date:
Owner's Name:
Patient's Name:
Referring Hospital:
Referring Hospital Phone:
Referring Hospital Email:
Referring Veterinarian:
Species:
Breed:
Age:
Sex:	M F MN FS
Current Weight:
Primary Complaint / Reason for Referral:
Laboratory / Radiographic Results:
Diagnostic Procedures Requested:	Internal Medicine Consultation Cardiopulmonary Evaluation Thoracic Ultrasound Abdominal Ultrasound Ultrasound Guided Fine Needle Biopsy Ultrasound Guided Core Biopsy CT/MRI Scan Surgery Consultation Orthopedic Consultation Cystoscopy / Vaginoscopy Endoscopy / Colonoscopy Bronchoscopy / Rhinoscopy 24-Hour Care Other

Please complete and send this form to us the day before our arrival and admit the patient(s) to your hospital by 8:00AM on the scheduled appointment date. If your patient is being referred to our office, please send this form, pertinent medical records, laboratory results and radiographs. Twelve hour fasting is requested for all abdominal ultrasound examinations and procedures requiring sedation or anesthesia.