New Patient Referral East Valley86 W. Juniper Ave. Suite 2 Gilbert, AZ 85233 Cardiology Internal Medicine Scottsdale22595 N. Scottsdale Rd. Suite #120 Scottsdale, AZ 85225 Cardiology West Valley7823 W. Golden Lane West Entrance Peoria, AZ 85345 Cardiology Internal Medicine Outpatient Radiology Ultrasound Radiography CT* Referring Veterinary Hospital InformationReferring Veterinarian’s NameDate Date Format: MM slash DD slash YYYY Hospital NameAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred method of contactPhoneFaxEmailPatient InformationPatient Name*Breed*Species*CanineFelineDate of Birth*Sex*MaleFemaleColor*Altered*YesNoHistory & specific concerns / requestsClient Name* First Last Phone*Phone Type*HomeMobileWorkGeneral Information: This form is appreciated for all cardiology and internal medicine referrals and is mandatory for all outpatient services offered by radiology in addition to the Radiology Services Request Form. This helps ensure that we are assisting in the care of your patient in the best way possible. The below items are also required prior to scheduling the procedure and required for all referrals. They can be submitted by email, fax, or uploaded below. Last 12 months of medical records Last 12 months of lab results Any diagnostic images and reports Any other information you may find pertinent to the patient’s medical needs/concerns *rDVM must call prior to owner scheduling appointment and speak with a radiologist for outpatient CT Files Drop files here or Name of individual who completed this form*Date* Date Format: MM slash DD slash YYYY