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