Patient Referral Form

Patient Referral Form
Please complete our online Patient Referral Form below to refer a patient to Ebensburg Animal Hospital. Our preferred method of receiving forms is via an email sent to eahsurgery@gmail.com. If you are unable to send it to us via email then please fax us at (814) 471-6907.
Specialty Referral To*

SurgeryCT Advanced ImagingUltrasound
Referring Veterinarian
Dr. Name*

First NameLast Name
Clinic/Practice Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax*
Email*
example@example.com
Patient Information
Client (Owner)*

First NameLast Name
Client (Owner) Phone Number*
Please enter a valid phone number.
Client (Owner) Email
example@example.com
Patient Name*
Patient Breed
Patient Classification*
Gender*

MaleFemale
Neutered / Spayed?*

YesNoUnknown
Patient Age*
Patient Color*
Vaccinations (Date of Last): Distemper

MonthDayYear
Date
Vaccinations (Date of Last): FeLV

MonthDayYear
Date
Vaccinations (Date of Last): Rabies

MonthDayYear
Date
Vaccinations (Date of Last): HWT

MonthDayYear
Date
Medical Details
Current Problem (please indicate/describe chief complaint / onset / progression / treatments)*
Significant Past Medical History / Problems
Tentative Diagnosis Given to Client*
Diagnostic Tests*
Treatment / Medications*
Additional Comments
Additional letter / information sent with client?

YesNo
Other Information Provided

Medical RecordsRadiographsImagesSynopsis LetterOther
File Upload

Cancelof
Spam Blocker*
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Patient Referral Form

Referring Veterinarian

Patient Information

Medical Details