KSUVMTH Veterinary Referral Information

REFERRAL INFORMATION:

 Check if resubmitting information

*Referring DVM: 

Ref. DVM E-Mail: 
      
 *Address: 

*Phone: 
(Please Contact our Referral Coordinator at 785-532-5555
 if your contact information Changes)

*FAX: 

  *Client Name: 

       *Client Phone: 

*Service Requested:
 (To make multiple selections, hold down the CTRL key and
highlight selections by clicking on them with your mouse.)
Cardiology Dermatology Equine Medicine Equine Surgery Exotics Food Animal Medicine/Surgery Oncology Ophthalmology Small Animal Medicine Small Animal Surgery

PATIENT INFORMATION:

*Patient Name:   *Age:  

*Breed:   *Sex: Choose One Male Female Unknown

*Reason for referral: 

*Vaccination status: 

*On routine medication (heartworm, thyroid, others):   Choose One Yes No

*Type:

Current Therapy (include dates and dosages):

History:

Physical findings:

Problem/Tentative diagnosis:

Radiographic findings: clinical pathology and special diagnostic exam:
(please send copy with client if available):

Additional Information:

* I have explained to my client that the KSU VMTH charges for services rendered. 
       Outpatients are required to pay in full at time of discharge.  Inpatients are
       required to pay 60% of the estimate at time of admission and the remaining
       balance at the time of discharge.

Please Call for an appointment: 

Small Animals:                      785-532-5690
Large Animals:                      785-532-5700
Referring Vet Direct Line:   785-532-5555