Internal Medicine Referral Form :: Allies In Internal Medicine

Bringing Insight Onsite

Mobile Internal Medicine
Consultation and Endoscopy Services

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Date Of Referral Required

OWNER(S) INFORMATION (MANDATORY FIELDS*)

First and last name(s)* Required

Unit/suite/apt, street number, street* Required

City, province, postal code* Required

Home phone number* Required

Cell phone number

Work phone number

REFERRING VETERINARIAN INFORMATION (MANDATORY FIELDS*)

First and last name* Required

Practice name* Required

Unit/suite, street number, street name* Required

City, province, postal code* Required

Daytime phone number* Required

After hours phone number

Fax number* Required

Email (if available)* Required

INTERNAL MEDICINE REFERRAL REPORT PREFERENCE Required

PATIENT INFORMATION (MANDATORY FIELDS*)

Name* Required

Age or date of birth* Required

Species* Required

Breed* Required

Gender* Required

Last body weight and date* Required

Last vaccination date and type

Vaccinated for Leptospirosis* Required

FeLV/FIV status if known* Required

Reason for Referral Required

Known Drug or Anesthetic Reactions Required

PLEASE PROVIDE A SHORT CHRONOLOGICAL CASE HISTORY SUMMARY RELEVANT TO REASON FOR REFERRAL

(example: onset of problem, list of diagnostic testing done, summary of any treatments/medications attempted (drug/dose/duration) and any response to treatment, and list of any therapeutic diets tried and response. Please list current therapies and doses. Add another page if needed. Do not send entire patient record, only recent records relevant to reason for referral.

Case History Summary Required

PLEASE LIST CURRENT MEDICATIONS AND DIETS (include formulation + doses please) Required

Please attach copies of all recent or historical diagnostic testing performed (lab tests, cytology or histopathology reports, ultrasound or radiology reports) relevant to reason for referral.

Attachment 1

Attachment 2

Attachment 3

Attachment 4

Attachment 5

Attachment 6

Attachment 7

Attachment 8

Radiographs Required

LIST RELEVANT RADIOGRAPHS DONE AND DATE. Have radiographs available for review at the time of consultation appointment. Do not email radiographs.