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701-478-9299
4491 23rd Ave S Fargo, ND
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REFERRAL REQUEST FORM
Today's Date
(Required)
MM slash DD slash YYYY
Have you called RRAEH about this referral?
(Required)
Yes
No
Referral Information
DVM
(Required)
Clinic/Hospital
(Required)
Phone
(Required)
Fax
Email
(Required)
Client Information
Name
(Required)
First
Last
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Owner's Preferred Method of Contact
(Required)
Phone
Email
Animal Information
Name
(Required)
DOB
(Required)
Sex
(Required)
Breed
(Required)
Color
(Required)
Please check the appropriate referral plan(s):
(Required)
Referral for immediate care / evaluation - unstable patient needing immediate attention
Specialist referral – evaluated / work-up by board certified specialist Dr. Andy Carver DVM, DACVECC. - Full diagnostic ultrasounds, echo, medical workup/consult, bone marrows/hematology, etc.
Stable referral for procedure / evaluation
Diagnostics / Procedures **If stable outpatient CT is requested, please also fill out CT Referral Form **
Diagnostics / Procedures Selection(s)
(Required)
Abdominal /Thoracic ultrasound
Echocardiogram
Emergency CT
GI Endoscopy for FB
Rhinoscopy
Other
Other
(Required)
Referral Scheduling
(Required)
Client will call RRAEH to schedule
RRAEH to call client and schedule
Reason for referral/tentative diagnosis:
(Required)
Brief medical history related to referral:
(Required)
Owner/referring DVM expectation for this case:
(Required)
Medical Records Upload
Please upload complete medical records, laboratory results, radiographs, and reports. You can alternatively email or fax them to our hospital at time of request at
[email protected]
or (701) 478-9298.
Drop files here or
Select files
Accepted file types: jpg, pdf, Max. file size: 5 MB, Max. files: 10.
Consent
(Required)
I have reviewed and completed this form for submission to Red River Animal Emergency Hospital for the evaluation of my patient.
Referring Veterinarian Signature
(Required)
An estimate of cost will be provided at time of service to the client. If an estimate is needed prior to that, please contact us to discuss the case with the ER doctor on staff.
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Home
About Us
About RRAEH
Testimonials
Inspiring Tails
Our Charitable Fund
Our Team
Our Emergency Team
Our Oncology Team
Our Surgery Team
Our Administrative Team
Services
Emergency Services
Critical Care Services
Hemodialysis
Emergency Surgery
RCM Referral Surgery
Diagnostic Imaging
Blood Bank
Hero Board
Oncology
Careers
Current Openings
RRAEH Student Technician Program
Internships
Observation
Employee Benefits
Resources
Resources
FAQs
Pet Loss
Our Policies and Fees
Referring Veterinarians
Contact