DVM Referral Form

1
Requesting Veterinarian
Name of the veterinary hospital you are affiliated with
Your e-mail address (to send report to)
Your phone number (to discuss the case)
Client's First & Last Name
Client's Email
2
Patient's Information
Patient's Name
Canine
Feline
Species
Breed
Age (years)
Female
Female spayed
Male
Male neutered
Sex
3
Brief History
4
Type of Referral
Specialist Consultation
Specialist Procedure
5
If Specialist Consultation, which service or doctor are you requesting?* This field is required.
Critical Care (Dr. Davidson)
Critical Care (Dr. Sande)
Internal Medicine (Dr. Pacifico)
Neurology (Dr. Levitin)
Oncology (Dr. Baez)
Surgery (Dr. Miller)
6
If Specialist Procedure, which procedure are you requesting* This field is required.
Outpatient Ultrasound
Other
7
If other, please tell us more
8
For outpatient procedures, our doctors will not meet with the client directly. We will communicate only with you, the referring veterinarian, to obtain the patient history and provide you with the report, so that you can use it to manage the case with your client.* This field is required.
I understand and consent that I will communicate with my client and manage the case directly.
I do not agree to manage the case directly. I understand that a consultation with our specialist will be required before a procedure will be performed on the patient.
I don't understand. Please contact me directly.
9
How will you provide the pets records?
I will email records to records@eclipsevetcare.com
Upload the records now
10
Please upload the pet's records here* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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