Patient Referral Form Service Requested: Surgery - Dr. Kristy Broaddus, DVM, MS, DACVS Internal Medicine - Dr. Emily Austin, DVM, MS, DACVIM Referring Veterinarian’s information: Referring veterinarian: Clinic Number Phone (###) ### #### Email Fax: Preferred method of communication: Phone Email Fax Patient/Client information: Patient’s name: Canine Feline Female Male Spayed Neutered Age: Breed: Owner's Name First Name Last Name Contact Number: (###) ### #### We want the patient to have the best experience possible when coming in for a consultation; would this patient benefit from sedative premedication? If yes, please prescribe and note below Brief description of the patient’s history and current treatments: (Please attach a copy of the medical record and all relevant diagnostics) Diagnostics Performed: Bloodwork (select all that apply): CBC Chemistry Sedivue T4 SDMA Other Radiographs/Ultrasound Sending diagnostic images with client Emailing diagnostic images. (please send to the referral practice email listed at the top of this form) Thank you!
