Veterinary Health Center at Kansas State University
Veterinary Referral Information

REFERRAL INFORMATION

All fields are required.

Check if resubmitting 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:

PATIENT INFORMATION:

All fields are required.

Name:	Breed:
Patient Sex:	Age:
Vaccination Status:
Reason For Referral:
On routine medication (heartworm, thyroid, others):		Type:

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:

	Sending ASAP
	Owner will Schedule

Additional Information (medical record and/or radiographs) should be emailed to Roblyer@vet.k-state.edu

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

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