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REFERRAL INFORMATION All fields are required.
REFERRAL INFORMATION
All fields are required.
* Please contact our Referral Coordinator at 785-532-5555 if your contact information changes.
PATIENT INFORMATION: All fields are required.
PATIENT INFORMATION:
Current Therapy (include dates and dosages):
Patient History:
Physical findings:
Problem/Tentative diagnosis:
Radiographic findings: clinical pathology and special diagnostic exam: (please send copy with client if available):
Additional Information:
Additional Information (medical record and/or radiographs) should be emailed to Roblyer@vet.k-state.edu