Referral Form 2025

Thank you for giving us the opportunity to care for your pet(s).

So that we may become better acquainted, please complete the following:

Date

Section A: Client Information:

Client Name*

Spouse/Secondary

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone*

This phone is able to receive text messages*

YesNo

Alternate Phone*

This Phone is able to receive text messages*

YesNo

Email*

example@example.com- if no email please put "null@null.com"

Section B: Patient Information:

Patient Name*

Species*

Other: Please specify

Breed*

Color/markings*

Date of Birth/Age*

Sex*

Is this animal spayed or neutered*

YesNoUnknown

Any special considerations?

Used for ShowBreedingWorkingOther

Date of last Rabies

Date

Reason for Referral*

Current Medications

Section C: Referring Clinic Contact Information:

Referring Veterinarian*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone*

Fax

Email

example@example.com

* Please request that rabies vaccination information, exam notes pertaining to the reason for referral, and all x-rays and bloodwork from the last six months be included in records.

Records will be sent by:*

EmailFax

Payment Policy: All charges must be paid in full at the time of service. A deposit may be required prior to scheduling any surgical treatment. We no longer accept personal checks for orthopedic surgeries. We accept the following payment methods: Cash, Visa, MasterCard, Discover, American Express, and CareCredit. Credit Card Surcharge: A 2.5% surcharge will be applied to all payments made via credit card. This fee covers processing costs and is not greater than our cost of acceptance. Late Payments & Collections: Finance charges of 1.5%per month (minimum $3.00) apply to all accounts over 30 days past due. Any outstanding balance unpaid in collections will be subject to a collections fee of 33% of the unpaid balance. You as the client will be responsible for any legal fees or additional costs incurred in the collections process, if applicable. By signing below, you acknowledge and agree to the terms of this billing policy, including your responsibility for any unpaid balances, applicable surcharges, and collection-related fees.