Internal Medicine Referral FORM — Rangiora Vet Centre

RVC Internal Medicine Referral Form

This form should be filled in by veterinary professionals only - to submit a referral please complete the form below and press submit. Your client will be contacted by our referral team directly to book an appointment.

For emergencies please phone (03) 313 7438 before submitting this form.

REFERRING VET

Vet Name:

First Name

Last Name

Vet Clinic:

Vet Email:

Vet Phone:

OWNER DETAILS

Animal Owner Name

First Name

Last Name

Animal Owner Phone:

Animal Owner Email

Animal Owner Address

ANIMAL DETAILS

Animal is being referred for:

Animal Name

Animal Date of Birth

MM

DD

YYYY

Animal Weight

Species / Breed

How quickly does the animal need to be seen?

Emergency (Same day)

Urgent (Within 2 days)

Not urgent (within 2 weeks)

Is the patient infections?

Yes

Possibly

No

Has there been any previous workup?

Recent blood results:

Does the animal have any ongoing conditions?

Is the animal currently on medication? (Please include doses)

If the animal is insured please note the insurance company & policy#

Is this referral:

A continuation of a current insurance claim?

A new insurance claim?

Unsure of insurance status.

** Please ensure you send all additional history, previous lab results, images etc directly to medicine@rangvet.co.nz

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RVC Internal Medicine Referral Form

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