Referral Form
Fill out the form below in its entirety. We will contact the client within 72 hours to set up a consult appointment (unless marked urgent). If needing a same day transfer, please call our Brooklyn Park location directly at 763.463.9800.
Referral service:
*
Surgery
Cardiology
Emergency
Oncology
Referral timeline:
*
<24hrs (please call)
24-48hrs
48-72hrs
>72hrs (non-urgent)
Referring Hospital Information
Hospital Name
*
Referring DVM Name
*
First Name
Last Name
Hospital Phone
*
Please enter a valid phone number.
Email (or fax if no email)
*
example@example.com
Owner Information
Owner Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Information
Pet Name
*
Date of Birth or Age
Weight (kgs)
Species
*
Please Select
Canine
Feline
Breed
*
Sex
*
Please Select
Intact Male
Neutered Male
Intact Female
Spayed Female
Rabies Due Date
-
Month
-
Day
Year
Date
Infectious?
*
Yes
No
Fractious/Aggressive?
*
Yes
No
Reason for Referral
Primary Problems and Expectations
*
Pertinent Medical History/Vaccine History
Medical Records
Browse Files
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Choose a file
Cancel
of
Lab Results
Browse Files
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of
Radiographs
Browse Files
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of
Submit
Should be Empty: