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Patient Referral - Birmingham Veterinary Internal Medicine
Please complete the following form to refer a patient to Birmingham Veterinary Internal Medicine.
Patient Referral - Birmingham Veterinary Internal Medicine
Primary DVM name
*
Primary Care Practice
*
Best phone to reach referring veterinarian
*
Email for confirmation
*
Client name
*
Client phone
*
Client email
Pet name
*
Species
*
Canine
Feline
Breed
*
Sex
Female, intact
Female, spayed
Male, intact
Male, neutered
DOB or estimated age
*
Weight
*
Immunizations Current
*
Yes
No
Patient History
Tentative Diagnosis
Current Treatment/Medications
*
Please send all recent radiographs, pertinent medical history and blood work from the last six months with your client.
Thank you for your confidence in this referral. We sincerely appreciate your support.
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