Referring Veterinarian Surgery Request Form
This form is intended for use by referring veterinarians. If you are a client, please fill out the 'Client Surgery Request Form' found in the main menu.
Name of Referring Veterinarian (RDVM)
*
First Name
Last Name
RDVM Information
*
Name of Clinic
RDVM/ Clinic Phone Number
Patient & Client Information
Pet's Name
*
Pet's Age
*
Please specify years or months
Sex and Castration Status
*
Please Select
FI
FS
MN
MI
Unknown
Pet's Species
*
Please Select
Feline
Canine
Pet's Breed
*
Client Name
*
First Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Client Email
*
example@example.com
Client DOB
-
Month
-
Day
Year
Date
Client Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
To your knowledge, has the client applied for financial assistance (for example, Care Credit or Scratchpay)?
*
Please Select
Yes
No
Surgery Case Information
Type of Surgery Requested
*
Please Select
Gastrointestinal
Splenectomy
Pyometra
C-Section
Cystotomy
BOAS
Fracture Repair
Other
If you have selected 'Other' please refer to our website to confirm we offer this surgery and clarify the type of surgery requested in the large text box below titled 'Please describe the case briefly'
Urgency of Surgery Request
*
Please Select
Emergency (same-day)
Urgent (1-3 days)
Non-Urgent (>3 days)
Unable to determine
To your knowledge, is the patient on any medications currently?
*
Please Select
Yes
No
If you have selected 'Yes', please list the medication(s) name, dose, and frequency in the box to the right.
List of current medications (if applicable)
To your knowledge, does the patient have any comorbidities we should be aware or?
*
Please Select
Yes
No
If you have selected 'Yes', please include a list of conditions/ diagnoses in the box to the right.
List of comorbidities (if applicable)
Please describe the case briefly:
Please Upload All Relevant Records, Imaging, and Bloodwork:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have you uploaded all relevant and/or requested records above?
*
Please Select
Yes
No
For a list of required or requested diagnostics, please reference the link below if you are unsure what this includes.
[insert required diagnostics link]
If you are unable to upload documents for any reason please contact us at 925-658-3631
Signature
*
By signing above, I certify that the information provided is true and correct to the best of my knowledge
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