THIS IS A TEST PAGE. PLEASE DO NOT USE. PATIENT REFERRAL INFORMATIONDate MM slash DD slash YYYY 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 directly at 208.375.1600 to schedule an appointment.REFERRAL TYPE (CHECK ALL THAT APPLY)Please select Emergency/Transfer Specialty Appointments Imaging 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.Specialty Appointment ReferralsPlease select Cardiology Dentistry/Oral Surgery Internal Medicine Neurology Oncology Ophthalmology Physiotherapy/Rehab 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.Please select 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.Other ReferralsPlease 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 directly at 208.375.1600 to schedule an appointment. Δ
