EMERGENCY CHECK-IN FORM

Referral Form

If you are a client’s regular veterinarian and wish to transfer a patient to Central Island Veterinary Emergency Hospital for overnight care, further diagnostics, or other, please complete this form. Once received, we will return an estimate for you to present to the client, so they have an idea of the approximate cost of care and the services provided.

 

If you have any questions about the referral of specific cases, feel free to phone ahead and speak to one of our veterinarians.


 

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REFERRING HOSPITAL INFORMATION

REFERAL DEPARTMENT

RELEVANT DOCUMENTS


Please include patient history, any medical findings, images or other files. ALL files should be sent to info@civeh.com.

 

It is highly recommended that all dogs 7 years or older receive 3-view chest radiographs and updated bloodwork (within the past month) prior to the referral. If the owner declines, let them know the Internal Medicine team may perform these diagnostics at the time of the consult. *

 

Documents sent include: *

CLIENT INFORMATION

PATIENT INFORMATION

ex: nervous, aggressive, calm, etc.

Please include the name of medications, dosage, and frequency of doses.

 

I acknowlege that I MUST include all diagnostics and lab work with a brief summary. If the referral form is incomplete, you will receive a request to resubmit the form. *
 

 

Security Question *