PETS Referral Center Specialty Appointment Request

Select Specialty Service *
Preferred Surgeon

Dr. John Moser Dr. Lauren Meltzer No Preference / First Available
Preferred Oncologist

Dr. Cecile Siedlecki Dr. Kim Shaffer Dr. Caroline Murray No Preference / First Available
Your Pets Name *
Your Name *

First Name Last Name
Primary Phone Number *
May we send you text messages at the above number? *

Yes No
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
Breed:
How old is {PetName} *
Is the above age:

Known Estimated
Sex *
Color
Reason for your consultation? *
Facility or veterinarian who recommended consultation *
Relevant History
Any Current Treatments/Medications
Include dosing if known along with any supplements
Primary Veterinarian
We will automatically send records to the clinic you list here. Please include city.
Upload any relevant records, images or videos (Optional)

Browse Files
10MB max size Cancel of
Submission Date

Month Day Year
Date
Submission Time

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

Patient Information