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Online Internal Medicine Referral Form

* Required
Click here for a printable version of this Form

Date *
Priority
Normal Emergency
DVM Name *
 Hospital Name *
Hospital Street Address   (Please omit if you refer regularly)
Hospital City
Hospital Zip
Hospital Phone
 Hospital Fax
DVM Email *
Has Patient Visited SFVS Previously?
Yes No
Pet Owner Name *
Owner Home Phone *
 Owner Work Phone
Owner Cell Phone
Owner Email
Pet Name *
 Pet Age *
Pet Gender *
Female Male
Neutered / Spayed Intact
Pet Weight *
 Pet Breed *
Vaccine History & Dates
Pet Behavior *
Good: no issues
Difficult to restrain
WILL BITE
Needs sedation
Brief History *
Laboratory Work *
Yes (please send to SFVS) None
Radiographs *
FILMS: referring DVM sending films to SFVS
FILMS: Pet Owner delivering films to SFVS
DIGITAL: Images being sent on disk
DIGITAL: Dicom images will be sent via online server connection
None

PLEASE NOTE:

The medical record and laboratory work may be faxed to 404-974-2006. Please send any radiographs and/or DICOM digital images on a CD/DVD with your client. You may transmit digital (DICOM) radiograph files via your PACS server directly to our PACS server. For help with PACS connectivity and file transfer, please contact Tommy Meers at 404-924-2000, ext.108. Please ensure that all images sent to SFVS are labeled with the patient name and hospital name. Please retain a copy of your CD/DVD discs, since these are not typically returned to the referring veterinarian.
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Saint Francis Veterinary Specialists
625 Dekalb Industrial Way, Suite 500
Decatur, GA 30033-5990
P: (404) 924-2000 | F: (404) 974-2006
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