Internal Medicine Referral Form (Dr. Hall)

SHERIDAN ANIMAL HOSPITAL
2288 Sheridan Drive • Buffalo, New York 14223
Telephone (716) 833-5345 • Fax (716) 833-8525

Please note: This form should be completed and submitted by the referring veterinarian, not the client.

Referring Doctor*

Referring Hospital*

Hospital Phone #*

Client Information

Owner's Name*

Phone Number*

Street Address

City, State

Zip Code

Patient Information

Patient's Name

Sex
MaleMale/neuteredFemaleFemale/spayed

Species

Breed

Color

Date of Birth/Approximate Age

Vaccination Dates (Rabies MUST be current):

Please attach ALL recent blood/labwork below:

Referral Information

Date Referred:

Duration of Problem:

Were radiographs done?
YesNo

If yes, they were:
EmailedDisc/Films Sent With OwnerOther

Reason for Referral:

Diagnostics performed (include all results):

Previous medical problems:

Current medications & dosages:

Dr. Hall is committed to returning your patient's care to your office as soon as possible. Please indicate who you would like to perform immediate follow-up care for the referred problem:

YourselfDr. HallTo be determined following patient evaluation

Referral letters should be emailed/faxed to: