Referring Veterinarians Form

Reason for Referral
Brief description of condition
Referral Services
- Internal Medicine (Endoscopy)
- Internal Medicine (Rhinoscopy)
- Internal Medicine (Ultrasound)
- Orthopedic Surgery
- Soft Tissue/Oncologic Surgery
- Oncology/Chemotherapy
- Abdominal Ultrasound Only (see bottom of page)
Patient Information
Pet's Name Breed Age in years Sex Weight (specify kg or lb)
Owner's Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referring Veterinarian Information
DVM Name Veterinary Hospital Name Best Telephone Number Email Address
Case Description
Please provide a brief description of history, exam findings, and current concerns
Prior Treatments for Referred Problem
Please list any prior treatments pertaining to this issue
Current Medications and/or Supplements
Referring Veterinarian Records
Please include all records, lab results, and diagnostic images
Drop files here or
Vaccine History*
Please provide current vaccination history. We will NOT send vaccination reminders to referred patients.
Drop files here or
Lab Results and Imaging
Please attach any lab results or imaging that are not directly linked to the patient record
Drop files here or
Emergency or Other Records
Please include any pertinent records that are not included within the referring DVM records
Drop files here or
Abdominal Ultrasound Only
No exam or direct client contact or communication and ultrasound results will be forwarded to referring veterinarian.
Owner permission for sedation*
Ultrasound images may be difficult to obtain in non-sedated patients