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College of Veterinary Medicine

Veterinary Health Center at Kansas State University
Veterinary Referral Information

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VHC Case Number:

REFERRAL INFORMATION

All fields are required.

Emergency - Sending ASAPOwner will Schedule

Check to update contact information

Referring DVM:
DVM Email:
Telephone:
Fax:

Service Requested:
	Ctrl + Click to select multiple services.

Address:
Address 2:
City:	State:	Zip Code:

* Please contact our Referral Coordinator at 785-532-5555 if your contact information changes.

Client's Name:

Client's Phone:

Address:
Address 2:
City:	State:	Zip Code:

PATIENT INFORMATION:

All fields are required.

Name:	Breed:
Patient Sex:	Date of Birth:
Known Allergies:
Patient Color:	Vaccination Status:
Reason For Referral:
On routine medication (heartworm, thyroid, others):		Type:

REFERRING DVM CONTACT PREFERENCES:

Preferred Contact Method:

Current Therapy (include dates and dosages):

Patient History:

Current Physical Findings:

Problem/Tentative diagnosis:

Radiographic findings; clinical pathology and special diagnostic exam: (please send copy with client if available):

Additional Information:

For 8-week TPLO Lateral and AP views of Stifle requested, attach below.

Attach Laboratory results, radiographs and medical records below. If submitting radiographs, please include at least two views.

Attachments (25MB Max):

Consultation/Referral:

Consultation OnlyConsultation w/ Possible ReferralReferral

I have explained to my client that the KSU VHC charges for services rendered. Outpatients are required to pay in full at time of discharge. Inpatients are required to pay 60% of the estimate at time of admission and the remaining balance at the time of discharge.

Please Call for an Appointment
Small Animals	785-532-5690
Large Animals	785-532-5700
Referring Vet Direct Line	785-532-5555
Referring Vet Fax	785-532-4900

Follow-up bloodwork	Follow-up TPLO (Attach lateral & AP views)
Please CallNo call needed unless treatment chages are necessary
If you do not receive a callback in a reasonable amount of time, please call (785) 532-5555.

Kansas State University

College of Veterinary Medicine

Veterinary Health Center at Kansas State University Veterinary Referral Information

Veterinary Health Center at Kansas State University
Veterinary Referral Information