Referral Form

Referral Form

Please complete the following form in its entirety to refer a patient to Animal Emergency Care.
Client Information
Client's Full Name*

First NameLast Name
Client's Phone Number*
Please enter a valid phone number.
Client's Email*
example@example.com
Pet/Patient's Name*
Breed/Species*
i.e. Ragdoll/Cat
Age*
Sex*

Female, intactMale, intactFemale, spayedMale, neutered
Referring Veterinarian Information
Veterinarian's Full Name*

First NameLast Name
Referring Practice*
Referring Phone Number*
Please enter a valid phone number.
Referring Vet's Email*
example@example.com
Referral Information
MEDICAL ADVISORY: Advanced Imaging and Specialty Services are not available outside the hours of 8:00 AM – 5:00 PM Monday-Friday.
Reason for Referral*
Medical History*
Medical History Documents (if available)

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Please review the following body systems. If abnormal, please provide additional details in the box at the bottom of this section.
Vitals*

N/ANormalAbnormal
Integumentary*

N/ANormalAbnormal
Musculo-Skeletal*

N/ANormalAbnormal
Circulatory*

N/ANormalAbnormal
Respiratory*

N/ANormalAbnormal
Digestive*

N/ANormalAbnormal
Genito-Urinary*

N/ANormalAbnormal
Eyes*

N/ANormalAbnormal
Ears*

N/ANormalAbnormal
Neural Systems*

N/ANormalAbnormal
Lymph Nodes*

N/ANormalAbnormal
Dental*

N/ANormalAbnormal
Additional Details
Did you perform any of the following diagnostic tests? If abnormal, please provide additional details in the box at the bottom of this section.
Radiographs*

N/ANormalAbnormal
Ultrasound*

N/ANormalAbnormal
ECG*

N/ANormalAbnormal
Chemistry*

N/ANormalAbnormal
Electrolytes*

N/ANormalAbnormal
CBC*

N/ANormalAbnormal
Blood Gases*

N/ANormalAbnormal
Urinalysis*

N/ANormalAbnormal
Toxins*

N/ANormalAbnormal
SNAP Test*

N/ANormalAbnormal
Cytology*

N/ANormalAbnormal
Fluid Analysis*

N/ANormalAbnormal
Additional Details
Diagnosis*
Diagnostic Documents (if available)

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Current Therapies*
Authorization
Acknowledgement of Financial Policy

Animal Emergency Care PLLC (AEC) requires payment at time of service and accepts cash, all major credit cards, Care Credit, Scratch Pay, and electronic checks. Electronic checks are authorized by a third-party institution and will require the name, address, phone number, and state identification card information to authorize payment. AEC does not have the ability to offer in-house financing and does not extend credit directly.

AEC requires a deposit in the amount of the high end of the quote provided on the treatment plan for all inpatient procedures including hospitalization and/or surgery. The cost of daily hospitalization is generally $1,285.39-$2008.97 for stable patients and $2,231.55-$2557.17 for critical patients. These estimates do not reflect any guarantee by AEC. These estimates serve to gauge whether transfer to our facility is feasible for the client.
My signature certifies that the referring client has been made aware of the costs they may incur at Animal Emergency Care.*

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Referral Form

Client Information

Referring Veterinarian Information

Referral Information

Authorization