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The University of Georgia College of Veterinary Medicine Home

Small Animal Internal Medicine Consultation Form
for Referring Veterinarians

  • Referring DVM
    First Name:   Last:
  • Phone #:
  • Evening Phone #:
  • Fax #:
  • E-Mail:
  • Please indicate how you would preferto be contacted:
    Phone    Fax    E-Mail  

    •  

  • Patient Name:
  • Owner
    First Name:   Last:
  • Dog    Cat    Other   Breed:
  • Age:   Gender:   Weight(Kg):

    •  

  • Please tell us the specific reason(s) for your consult today(ie,the question(s) we need to make certain to address)

    •  

  • Please provide pertinent clinical history in the space provided(problem list, diagnosis)

    •  

  • Please describe physical examination findings in the space provided

    •  

  • Please summarize diagnosis results, including dates performed, in the space provided (CBC, chemical profile, UA, radiographs/ultrasound, other specific testing)

    •  

  • Please summarize prior treatments (include dates), response to treatments, and any current therapies with doses

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  • One of the internists will contact you to discuss this consult, typically within 24 hours. Because of the nature of our clinic schedule, it is frequently after 6pm when we are available to call, so please be sure to include an evening phone number.

    Your consults are so often excellent teaching material for the students on the internal medicine rotation that we have incorporated them into this process. One of our students will be assigned to investigate your case, and will be able to listen in (or read along) when we contact you.

    Thank you for your support of our program!

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