Online Referral Form – Internal Medicine

EMERGENCY REFFERALS(Required)

PLEASE DO NOT USE THIS FORM FOR EMERGENCY REFERRALS. INSTEAD CALL OUR OFFICE AT 919-489-0615 TO SPEAK DIRECTLY TO A CLINICIAN.

My patient does not need to be referred to the emergency department

Sedation Needed?(Required)

Referring Veterinarian(Required)

First Last

Referring Hospital(Required)

Hospital Phone Number(Required)

Client Name(Required)

First Last

Pet Name(Required)

Client Phone Number(Required)

Species(Required)

Breed(Required)

Age(Required)

Sex(Required)

Reason for Referral(Required)

Findings and Diagnostics Performed(Required)

Radiographs(Required)

Will radiographs be submitted to [email protected] prior to the patient appointment?

Yes

Current Medications(Required)

Additional Comments

Behavioral Concerns or Medications

Follow Up

How would you like the next contact to be made? If selecting "TVRH to call client", our CSR team will reach out to the client within 36 hours of receiving this referral. If selecting DVM-to-DVM consult, email us at [email protected] with a case summary including the clinical signs, diagnostics performed (including dates and results), treatments attempted, response to each attempted treatment and your specific questions. Medical records can be attached or sent to [email protected], but a written summary is required. Our clinician is happy to offer guidance. Average turnaround time for stable doctor-to-doctor consults is 3-10 business days.

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Online Referral Form – Internal Medicine

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