Patient Referral Form

This form can also be downloaded by clicking here if you would rather print it out and fax it to us at (719) 564-0514 or you can e-mail it to us at internalmedicine@pueblopetvet.com.

Please call us if you have any questions regarding your patient’s referral!

Internal Medicine Referral Form

This form is for referring primary veterinarians to fill out and submit to our Internal Medicine Service so that we can begin to schedule an appointment with their referred clients.

Date*
Client Information
Client Name*
First Last
Primary Phone*
Alternate Phone
Email Address
Alternate Contact Name
First Last
Alternate Contact Phone
Patient Information
Patient Name*
First
Species*
Date of Birth*
Breed*
Sex*
Color*
Primary Care Veterinarian Information
Primary Care Hospital*
Veterinarian*
Phone*
Cell Phone
The primary veterinarian's cell phone number will only be used for Dr. Caroline Landry to contact them after hours with results if the veterinarian would like. This cell phone number will not be given to any one other than Dr. Caroline Landry.
Would you like to be contacted after hours?*
Fax Number*
Email
Check preferred method of referral communication:*
- Phone
- Fax
- Email
Reason for Referral
*
Additional Medical History
Please send copies of any recent blood work and radiographs along with the patient to their appointment. Thank you for the referral!

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Internal Medicine Referral Form

Client Information

Patient Information

Primary Care Veterinarian Information

Reason for Referral

Additional Medical History

Please send copies of any recent blood work and radiographs along with the patient to their appointment. Thank you for the referral!

In this section

Patient Referral Form

Internal Medicine Referral Form

Client Information

Patient Information

Primary Care Veterinarian Information

Reason for Referral

Additional Medical History

Please send copies of any recent blood work and radiographs along with the patient to their appointment. Thank you for the referral!

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In this section