Referral Instructions:

  1. Health care practitioner, please complete this document.
  2. Recent lab results for IV patients: Please fax or email to Vital Kids Medicine. This is VERY important in order for us to provide SAFE IV treatments to your patient. If there are no recent labs results, your patient’s first visit with us may be limited to intake and ordering of labs without any IV treatment. See below for pre-IV labs.

To: Vital Kids Medicine
Address: 3216 NE 45th Place, Suite 212
Phone/fax: (206) 518-8938 / (206) 525-3273

  • Referral Information

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • SECTION 2 - Requested Action: Referral

  • Select all that apply
  • Select all that apply
  • Select all that apply
  • Select all that apply

Recommended Pre-IV Labs: -All IV patients: CBC, ferritin, comprehensive chemistry (including hepatic function and BUN/ Creatinine) -Heavy metal toxicity patients will additionally need: urinalysis, EKG, minerals including (RBC Zinc, Magnesium, ionized calcium, selenium), Thyroid panel, (heavy metal provocative challenge IV testing done at VKM) -Additional screenings as needed: G6PD, lipid panel, amino acid profile, endocrine profiles, fatty acid profile, vitamin profiles

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