In order to have your patient scheduled for an initial consultation with one of our specialists, please complete the referral sheet below. Additionally, please send all records pertaining to the case, including laboratory, radiograph, ultrasound, and advanced imaging (images and radiologist reports), to allow us to best help your patient and client within their scheduled appointment time.
Date
-
Month
-
Day
Year
Referrer Information
Referring Veterinarian Name
*
First Name
Last Name
Hospital Name
*
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Patient Information
Name
*
Species
*
Canine
Feline
Age
Sex
Female Intact
Female Spayed
Male Intact
Male Neutered
Breed
Client Information
Client Name
*
First Name
Last Name
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Email
example@example.com
Case Summary
Which service are you referring to?
*
Surgery
Dentistry/Oral Surgery
Neurology/Neurosurgery
Emergency
Reason for Referral
*
Clinical History
*
Current Medications
*
Previous Diagnostics
Please attach OR send in a seperate email all diagnostic results including imaging report and images (or link to DICOM images).
Lab work performed within the last 30 days?
Complete Blood Count
Serum Chemistry
Urinalysis
Other
Radiographs
Thoracic
Abdominal
Appendicular
Vertebral
Other
Ultrasound
Echocardiogram
Abdominal
Thoracic
Other
CT
Head
Spine
Thorax
Abdomen
Appendicular
Other
MRI
Head
Cervical Spine
Thoracic Spine
Lumbar Spine
Other
Submit
Should be Empty: