Patient Referral Form
Please fill out this patient referral form in its entirety to ensure we can provide your clients and patients with the best possible care.
Client First Name
Client Last Name
Please enter a valid phone number.
Pet Age in Years
(e.g., Labrador, Siamese, Mixed Breed)
Name of Referring Vet
Referring DVM Email
Name of Referring Facility
When referring for specialty services, please upload completed medical records, diagnostics, and images so our team can best support your clients and patients.
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pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Referred to MarQueen for: (please select all that apply)
24-hour/365-day ER/Boarded Critical Care
Endoscopy/Foreign Body Retrieval
24-hour Board Certified Surgery/Consult – Dr. Peter Walsh
Radiologist Ultrasound – VMI Group*
CT Scan (Includes anesthesia, one study with VMI read, and day board)*
Cardiology Emergency – Dr. Brian MacKie*
Cardiology Non-Emergency – Dr. Lori Siemens*
*Note: For ALL imaging requests, please also fill out our
imaging referral request form.
Please add any information that is pertinent to the patient's reason for referral.
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9205 Sierra College Blvd, Suite 120
Emergency & Surgery:
9213 Sierra College Blvd, Suite 150
Roseville, CA 95661
Should be Empty: