RDVM Referral Form

Referral Veterinarian Information

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Referring Doctor's Name*

First NameLast Name
Name of Animal Hospital
Email
example@example.com
Phone Number
Please enter a valid phone number.
Patient Information
How soon does the patient need to be seen?*

Emergency - same day appt- if your patient needs to be seen on emergency basis, please call our office immediately. If patient is experiencing an emergency after business hours, please contact the VEC.Urgent- 3 to 5 days - please call our office for our work in/urgent care visit availabilityRoutine - within 7 to 14 daysElective - non-priority, able to wait for availability based on current schedule.
Owner Name *

First NameLast Name
Owner Phone Number *
Please enter a valid phone number.
Owner Email (optional)
example@example.com
Patient Name *
Signalment (species, breed, age, neutered or intact)*
Chief Complaint*
Please check any of the previous known medical problems in the patient's history*

SeizuresDiabetes mellitusCancerHistory of immune-mediated diseaseBladder stonesPancreatitisHyperthyroidismHeart diseaseRenal diseaseLiver diseaseHyperadrenocorticismHypoadrenocorticismPrevious major surgeryNone of the above
If you checked yes to any of the above medical problems, please elaborate here
Has the patient had any of the following signs of fear, anxiety, or stress?*

Growling, hissing, lunging, or bitingRequiring a muzzle for veterinary visitsUse of pre-visit pharmaceuticalsNone of the above
Current/Recent Medications (including prescription diet)*
Response to current medications?

Condition worseNo improvementPartial ImprovementComplete resolution
Has patient been on NSAID in past week?*
Has the patient been on steroids (oral, topical, injectable) in past week?*
Has patient been on antibiotics in the past week?*
What are the owner's expectations for the referral?*

Abdominal ultrasoundPossible FNA or biopsyEchocardiogramEndoscopyOther
If you checked other, please elaborate here
Which prescription diets do you routinely carry at your hospital?

HillsRoyal CaninPurina
Please send all pertinent medical records, lab work, and radiographs to team.vetspecialtysolutions@gmail.com.
Thank you for allowing Veterinary Specialty Solutions to be part of the healthcare team.
Should be Empty:

Referral Veterinarian Information

Patient Information

Please send all pertinent medical records, lab work, and radiographs to team.vetspecialtysolutions@gmail.com.

Thank you for allowing Veterinary Specialty Solutions to be part of the healthcare team.