Safe Haven Patient Referral Form

INTERNAL MEDICINE

We recognize the importance of mutual respect and collaboration as we work to provide exceptional patient care. Together, we can do more than the sum of our individual actions.

Please complete the below for INTERNAL MEDICINE:

Primary or Requesting Provider Information

Veterinary Practice:(Required)

Name of Veterinary Practice

Referring Veterinarian:(Required)

First Last

Phone:(Required)

Preferred means of contact:(Required)

Email:(Required)

FAX:

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Information

Name:(Required)

First Last

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact Phone Number:(Required)

Alternate Phone Number(s):

Additional Name on Account:

First Last

Phone Number:

Additional Name on Account:

First Last

Phone Number:

Patient Information

Name:(Required)

Name of Patient

Species:(Required)

Dog

Cat

Sex:(Required)

Breed:(Required)

Color:(Required)

Weight:(Required)

Age/Date of Birth:(Required)

Referral Information

Reason for Referral:(Required)

Brief History:(Required)

Diagnosis/Presumptive Diagnosis:(Required)

Please attach any pertinent medical records, test results, etc.:

Drop files here or

Max. file size: 64 MB.

Services Desired:(Required)

Urgent Care

IM Consultation Only

IM Consultation with Diagnostics

Please specify any specific diagnostics your patient needs:

Phone

This field is for validation purposes and should be left unchanged.

Please call with any additional information or expectations. Results and recommendations will be sent to your facility via email unless otherwise instructed.

Safe Haven Patient Referral Form

INTERNAL MEDICINE

We recognize the importance of mutual respect and collaboration as we work to provide exceptional patient care. Together, we can do more than the sum of our individual actions.

Please complete the below for INTERNAL MEDICINE:

Primary or Requesting Provider Information

Client Information

Patient Information

Referral Information

Please call with any additional information or expectations. Results and recommendations will be sent to your facility via email unless otherwise instructed.

(724) 591-8393

Hours:

13085 Perry Hwy, Wexford, PA 15090