Referral Request Form Today's Date* Date Format: MM slash DD slash YYYY Have you called RRAEH about this referral?*YesNoReferral InformationDVM*Clinic/Hospital*Phone*FaxEmail* Client InformationName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Owner's Preferred Method of Contact*PhoneEmailAnimal InformationName*DOB*Sex*Breed*Color*Please check the appropriate referral plan(s):* Referral for immediate care / evaluation - unstable patient needing immediate attention Specialist referral – evaluated / work-up by board certified specialist Dr. Andy Carver DVM, DACVECC. - Full diagnostic ultrasounds, echo, medical workup/consult, bone marrows/hematology, etc. Stable referral for procedure / evaluation Diagnostics / Procedures **If stable outpatient CT is requested, please also fill out CT Referral Form ** Diagnostics / Procedures Selection(s)* Abdominal /Thoracic ultrasound Echocardiogram Emergency CT GI Endoscopy for FB Rhinoscopy Other Other*Referral Scheduling*Client will call RRAEH to scheduleRRAEH to call client and scheduleReason for referral/tentative diagnosis:*Brief medical history related to referral:*Owner/referring DVM expectation for this case:*Medical Records UploadPlease upload complete medical records, laboratory results, radiographs, and reports. You can alternatively email or fax them to our hospital at time of request at email@example.com or (701) 478-9298. Drop files here or Accepted file types: jpg, pdf. Consent* I have reviewed and completed this form for submission to Red River Animal Emergency Hospital for the evaluation of my patient.Referring Veterinarian Signature*An estimate of cost will be provided at time of service to the client. If an estimate is needed prior to that, please contact us to discuss the case with the ER doctor on staff.