PETS Referral Center Specialty Appointment Request

Select Specialty Service*
Your Pets Name*
Your Name*

First NameLast Name
We ask for your date of birth to ensure we meet regulatory guidelines when providing medications for your pet. Thank you for your understanding and cooperation!
Your Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / 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?*

NoYes
Patient Information
Has {PetName} been to PETS Referral Center previously?

NoYes
Photo of {PetName} (Optional)
Species:*

CatDogOther
Exotics Species:
*No dogs or cats
Breed:
How old is {PetName}*
Is the above age:*

KnownEstimated
Sex*
Color
For patients seeking an Oncology appointment: Has your pet been diagnosed with Cancer?

YesNoI am not seeking an Oncology appointment
Reason for your consultation?*
If scheduling with Oncology, has your pet seen an oncologist previously?*

YesNoI am not scheduling with oncology
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)

Browse Files
10MB max size Cancelof
Submission Date

MonthDayYear
Date
Submission Time

:HourMinutesAM/PM Option
Appointment Status
Staff Notes
System Email
example@example.com
Should be Empty:

We ask for your date of birth to ensure we meet regulatory guidelines when providing medications for your pet. Thank you for your understanding and cooperation!

Patient Information