425.823.9111

11814 115th Ave NE, Bldg J
Kirkland, WA 98034
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Specialty Form

To facilitate a smooth transfer, contact us at (425) 823-9111 prior to sending client.

Referring Hospital Information:
Referred By Dr.
Referring Hospital:
Phone:
Fax:

Client/Patient Information:

Name of Client:

Phone #1:

Phone #2:

Patient's Name:

Species:

Breed:

Sex:

Age:

Case Status :

	Emergency (within 24 hours)
	Priority (within 48 hours)
	Routine (next available)

Tentative Diagnosis/Chief Complaint:

History/Physical Findings:

Lab Results:

Current Treatments/Medications:

Special Request/Comments:

Verification:
copy the digits from the image into the box below

Send the images with the client and fax all other history, lab work, treatment, etc. Thank You!

The complicated nature of many cases, it is very helpful if you can fill out a referral form to consolidate the pertinent history, laboratory and prior treatment data. This helps us help your patient in a more informed, efficient manner.

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