Cindy Duesberg | DVM, DACVIM
Kerrie Chung | DVM
Michelle Lin Cieplucha | DVM
Victoria Vorathavorn | DVM, DACVIM
2965 Edinger Ave. I Tustin, CA 92780 I P 949.653.2846 I F 949.653.2847 I www.advancedvetIM.com
REFERRAL FORM
Date / /
REFERRING HOSPITAL INFORMATION
Referring Doctor:
Hospital Name:
Hospital Address:
Phone: Fax: Email:
Preferred Communication: Fax E-mail Phone _____________________________________________
When do you wish to be contacted (check all that apply) Before Consultation After Consultation Both
Please specify which days you are available (check all that apply) M T W Th F Sa Su
Are there any associates that we may speak to about the case?
CLIENT INFORMATION
Owner’s Name: Phone:
Pet’s Name: Breed:
Age: Weight: Sex: M F MN FS
Pet’s Disposition (check all that apply) Anxious Caution (go slow) Major Caution (needs muzzle)
REASON FOR REFERRAL
Consultation: Endocrine Hepatic Urinary Hematologic Respiratory Gastrointestinal
Ultrasound: Cardiac/Thoracic Abdomen Other _____________________________ w/aspirate/biopsy
Endoscopy: Upper GI Lower GI Nasal Bronchi Laparoscopy Other ______________________
PRESENTING PROBLEM(S)
Active Problem Duration Severity Past Pertinent History
1)
2)
3)
4)
5)
DIAGNOSTIC TESTS PERFORMED: (please list and provide)
1)
2)
3)
TREATMENTS/MEDICATIONS ADMINISTERED: (please list and specify response to treatments/medications)
Treatments/Medications Favorable Response Unfavorable Response No Response
1)
2)
3)
4)
5)
ADDITIONAL COMMENTS
5 13355
73
261
241
405
Building Is OnThe Left
Edinger
NORTH
Directions:
From Los Angeles/ North Orange County: Take the I-5 South toward San Diego. Take the Jamboree Rd exit and turn right. Follow the signs toward Edinger Ave. Turn right on Edinger Ave. Turn right into Jamboree Plaza. BUILDING IS LOCATED DIRECTLY IN FRONT OF YOU ON THE LEFT. From San Diego/ South Orange County: Take the I-5 North. Exit Jamboree Road and make a left. Follow the signs toward Edinger Ave. Turn right on Edinger Ave. Turn right into Jamboree Plaza. BUILDING IS LOCATED DIRECTLY IN FRONT OF YOU ON THE LEFT. From Riverside/ San Bernardino County: Take CA-91 West to the CA-55 South. Then, take the I-5 South toward San Diego. Exit Jamboree Road and make a right. Follow the signs toward Edinger Ave. Turn right on Edinger Ave. Turn right into Jamboree Plaza. BUILDING IS LOCATED DIRECTLY IN FRONT OF YOU ON THE LEFT. Alternatively: Take the 91 West to 241 Foothill Transportation Corridor to the 261 Eastern Transportation Corridor to the Edinger exit. Turn right on Edinger. Turn right into Jamboree Plaza. BUILDING IS LOCATED DIRECTLY IN FRONT OF YOU ON THE LEFT.
PLEASE INCLUDE RADIOGRAPHS AND COPIES OF RELEVANT LABORATORY TESTS. RADIOGRAPHS WILL BE PROMPTLY RETURNED. YOU MAY WISH TO SEND THIS INFORMATION WITH THE CLIENT, OR SEND IT VIA MAIL, OR LABORATORY COURIER SERVICE. PHONE CONSULTATIONS ARE ALWAYS WELCOME AND ENCOURAGED. RADIOGRAPHIC CONSULTATIONS ARE AT NO CHARGE.
To all clients presenting animals: Please bring a leash or pet carrier to your outpatient, drop-off, and pick-up appointments. If your pet is scheduled for surgery, do not feed after midnight the night before the surgery. It is not necessary to withhold water. Bring any medication that your pet is currently receiving.
2965 Edinger Ave.Tustin, CA 92780
(949) 653-2846