THIS IS A TEST PAGE. PLEASE DO NOT USE. PATIENT REFERRAL INFORMATIONWestVet Location(Required)Select HospitalWestVet BoiseWestVet MeridianDate(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920WestVet Boise 5024 West Chinden Boulevard Garden City, ID 83714 Main: 208.375.1600 Fax: 208.375.1606 Email: clientcare@westvet.net WestVet Meridian 212 South Innovation Lane Meridian, ID 83642 Main: 208.813.6477 Fax: 208.563.5792 Email: referrals.meridian@westvet.netWestVet Urgent Care - Meridian 3030 South Meridian Road, Suite 110 Meridian, ID 83642 Main: 208.286.2368 Fax: 208.888.3562 Email: info.meridianuc@westvet.net Referring Veterinarian(Required) Hospital Name(Required) Phone Fax Doctors - Please give us your BEST contact number for today: Email(Required) Preferences for Initial Communication Telephone Email PATIENT/CLIENT INFORMATIONPatient Name(Required) Client's First Name(Required) Client's Last Name(Required) Client's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Client's Email The client will receive a copy of this referral form.Client's Phone(Required) Species Canine Feline Other Breed Sex M MN F FS Age Color Please ask your client to call WestVet Boise directly at 208.375.1600 to schedule an appointment.Please ask your client to call WestVet Meridian directly at 208.813.6477 to schedule an appointment.REFERRAL TYPE (CHECK ALL THAT APPLY)HiddenPlease select Emergency/Transfer Specialty Appointments Imaging Other Please Select Emergency/Transfer Specialty Appointments Imaging Other Please select Emergency/Transfer Internal Medicine Other Emergency/Transfer ReferralsTo more effectively serve your clients, please call 208.375.1600 and ask to speak to the emergency doctor on duty prior to all emergency transfers. Specialty services and procedures may not be available at all days/times.To more effectively serve your clients, please call 208.813.6477 and ask to speak to the emergency doctor on duty prior to all emergency transfers. Specialty services and procedures may not be available at all days/times.Specialty Appointment ReferralsPlease select Cardiology Dentistry/Oral Surgery Internal Medicine Neurology Oncology Ophthalmology Surgery Imaging ReferralsPlease Note: WestVet does not provide CTs or MRIs as outpatient services. Please prepare your patient for a consult with one of our specialists.HiddenPlease select from below Outpatient Ultrasound Review Images Provided: Radiographs must be attached and sent with this request (Select Upload) Please select from below(Required) Outpatient Ultrasound Review Images Provided: Radiographs must be attached and sent with this request (Select Upload) Your hospital will be invoiced for a radiology review and report fee.HiddenOther ReferralsHiddenPlease specify MEDICAL INFORMATION (Please attach all patient medical records)Presenting Complaint/History Physical Exam Findings Preliminary/Tentative Diagnosis Treatments performed, medication dosages and last time given: Pertinent Laboratory or Previous Imaging Results **Please include when sending records. (File Upload below) File Uploads(Required) Drop files here or Select files Max. file size: 128 MB. Specific Clinical Questions/Concerns Please ask your client to call WestVet Boise directly at 208.375.1600 to schedule an appointment.Please ask your client to call WestVet Meridian directly at 208.813.6477 to schedule an appointment. Δ
