Language
English (US)
Spanish (Latin America)
Select Specialty Service
*
Oncology
Ophthalmology
Surgery
Exotics (no dogs or cats)
Preferred Oncologist
Dr. Kim Shaffer
Dr. Caroline Murray
Dr. Cecile Siedlecki (Monday & Tuesday only)
No Preference / First Available
Your Pets Name
*
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email Address
*
example@example.com
Primary Phone Number
*
Any additional notes on how to best get in contact:
Have you been to PETS Referral Center with any pet?
*
No
Yes
Patient Information
Has {PetName} been to PETS Referral Center previously?
No
Yes
Photo of {PetName} (Optional)
Species:
*
Cat
Dog
Other
Exotics Species:
*No dogs or cats
Breed:
How old is {PetName}
*
Is the above age:
*
Known
Estimated
Sex
*
Female, Spayed
Female, Intact
Female, Unknown
Male, Neutered
Male, Intact
Unknown Sex
Color
For patients seeking an Oncology appointment: Has your pet been diagnosed with Cancer?
Yes
No
I am not seeking an Oncology appointment
Reason for your consultation?
*
Facility or Veterinarian who recommended consultation
*
Name of your Primary Veterinarian
*
We will automatically send records to the clinic you list here. Please include city.
Please list all Veterinary Hospitals you have visited with your pet in the last 6 months:
*
Relevant History
Any Current Treatments/Medications
Include dosing if known along with any supplements
Upload any relevant records, images or videos (Optional)
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Minutes
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AM/PM Option
Appointment Status
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Message Left
Staff Notes
System Email
example@example.com
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