Veterinarian Referral Form

Please fill out all relevant information in the form below.

If you have clinical notes in electronic format you can upload them by using the “Browse” button in the attachments section. Click the “Submit” link at the bottom of the page when you are finished. If you have questions, please contact us.

Referral Information

Select a Department

Emergency

Oncology

Internal Medicine

Ophthalmology

Determine Urgency

Routine

Priority

Emergency

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Referring Veterinarian

Dr. Name *

Hospital Name *

Email Address *

Phone *

Fax

Do you wish to be called if your patient's condition changes?

Yes

No

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Owner and Patient Information

Client (Owner) First Name *

Client (Owner) Last Name *

Client (Owner) Phone *

Client (Owner) Email

Pet Name *

Breed

Species *

Dog

Cat

Other

Gender *

Male

Female

Neutered / Spayed? *

Yes

No

Date of Birth

Color *

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Patient History

Current Problem (please indicate/describe chief complaint / onset / progression / treatments) *

Tentative Diagnosis Given to Client *

Current Medications

Significant Past Medical History / Problems *

A Referral Report will be faxed to you shortly after your client's visit. If you have another preference, please let us know.

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Treatments

Treatment at Referring Hospital

Medications / Injections / Fluids Given (include dosages and times)

Prognosis

Referring Doctor's Treatment Plan

Additional Comments

Other Information Provided

Medical Records

Radiographs

Images

Synopsis Letter

Other

Attach Medical Records

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