Surgical Referral Form
Affordable Options for Advanced Surgeries
Referring Doctor
*
First Name
Last Name
Referring Clinic
*
Clinic Phone Number
*
Please enter a valid phone number.
Clinic Email
*
example@example.com
Client Name
*
First Name
Last Name
Pet's Name
*
Species
*
Canine
Feline
Breed
Sex
*
Male
Female
Pet's Age
*
Brief History/Diagnosis:
*
Reason for Referral:
*
Would you prefer...
*
cases be referred back for rechecks and follow-ups
rechecks and follow-ups be performed at EPIC
Level of Urgency
*
Immediate
2-3 Days
Non-Emergent
Enclosures
Labs
Records
Radiographs
Other
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