Veterinarian Referral Form Companion

Veterinarian Referral Form
Owner's Name*

First NameLast Name
Co-Owner's Name

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Owner's Email*
example@example.com, if you do not have an email fill NA in the box
If yes, please explain*
Pet Name*
Species
Breed*
Color*
Gender*
Date of birth*

MonthDayYear
Date
YesNo
If yes, please explain*
REFERRING VETERINARIAN DATA
Name of Doctor*

First NameLast Name
Hospital*
Veterinarian Email*
example@example.com
Submitted By*
YesNo
If no, who is the regular veterinarian?
Expectation for this case
If your client will seek specialty treatment, procedure/surgery at VSES based on the results of these scans, it is our recommendation to have your client/patient start with a consultation with that department. Please reach out if you have questions.
Area to be Scanned:*
Examination only with treatment recommendationsExamination and diagnostics, +/- treatment recommendationsExamination with diagnostic, treatment, procedure/surgeryOther- please complete comment section to explain:
Significant/Previous Medical History (Including Allergies)*
Current Behavior Concerns (Please indicate/describe chief complaint, onset, progression, treatment, response)*
Current Treatment Recommendations Given to Client*
Current Medications*
VACCINE HISTORY
YesNo
MEDICAL RECORDS:

Please be sure to include all medical notes pertinent to the concern. If the concern has been ongoing for 6 months, please send everything for 6 months. If the concern has been ongoing for 6 years, please send everything for 6 years.

COMPLETED DIAGNOSTIC REPORTS:

If you have completed any of the following pertinent lab work or other test results, please attach original copies.

Diagnostic Reports

CBC
Chemistry
Urinalysis
Thyroid Testing
Pathology/Cytology
HW/Lyme/Ehrlichia
ECG
Blood Pressure
Surgery Reports Related to Concern
Image Reports
Radiographs
Ultrasound Studies
CT
MRI
Other
Patient Files
Medical Records*
Lab Results*
Diagnostic Images*
If sending records separately, email to companionvet.info@thrivepet.com.
Upload Medical Records

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Veterinarian Referral Form

REFERRING VETERINARIAN DATA

VACCINE HISTORY

Patient Files