Internal Medicine Referral "*" indicates required fields Clinic Name* Doctor's Name* Doctor's Email Address* Reason for referral* Client InformationClient Name* First Last Client Phone*Client Email Do you want to add the client's address? Yes No Address Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SignalmentPatient Name* Species* K9 Feline Spayed/Neutered* Spayed Neutered Date of Birth / Age Breed* Gender* Male Female Weight (kgs) Upload Patient RecordsUpload Patient Records HereMax. file size: 100 MB.If you would like to upload the patient's medical records you may do so here.Upload Diagnostic Imaging and Laboratory WorkType Radiographs CT MRI Ultrasound Blood Work Cytology Histopathology Other Upload Imaging / Laboratory Results Drop files here or Select files Max. file size: 100 MB. If you have any imaging or lab results that are separate from patient records, please include them here.Would you like to tell us about the patient's history here? Yes No If you have not uploaded patient records and would like to take the time to provide additional information about the patient, you may do so here.Describe the current problem, symptoms, and durationWhen was the animal last normal? Duration of symptoms?Vomiting?Diarrhea?Behavior changes?Changes in appetite?Changes in drinking habits?Changes in urination habits?Any noted weight loss?Any nutraceutical, herbal or homeopathic supplements?Current medications: name, dose (mg), frequency given, duration of therapy, side effectsCurrent diet? Type, amount, frequency of dietParasite preventation? Heartworm? Flea/tick? Intestinal?History of drug allergy/adverse reactionHave any treatments been used? Response to therapy?Would you like to tell us about the dogs environment Indoor Outdoor Fenced yard Free roaming Lake, pond or river exposure Hiking Dog park Boarding/grooming Travel outside of Alaska? Environment (other)Other pets in the home? Their health status?FeLV/FIV status (cats, if known)?Vaccine status? Rabies, DHPP (dogs), FVRCP (cats), leptospirosisIs there any other information you like us to be aware of?Other pertinent medical history
