VSS Specialty Department Referral Form
Please use this form for urgent or elective cases only. Any EMERGENCY cases should be transferred via phone as usual.
Referring Veterinarian
*
Referring Clinic/Hospital
*
Referring Clinic/Hospital Email
*
Referring Clinic/Hospital Phone Number
*
Format: (000) 000-0000.
Client First Name(s)
*
Client Last Name(s)
*
Client Email
*
Please provide your client's email address so that we may notify them of your referral for their pet and of our timeline for calling to schedule an appointment.
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Name
*
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Sex
*
Please Select
Male Neutered
Female Spayed
Male
Female
Patient Species
*
Please Select
Canine
Feline
Other
Patient Breed
*
Is this Case URGENT or ELECTIVE?
*
Please Select
URGENT
ELECTIVE
Specialty Service(s) to Which Patient is Being Referred (can select multiple)
*
Surgery/Orthopedics
Cardiology
Medical Oncology
Internal Medicine
Neurology (unavailable through November 2026)
Specialty Service to Which Patient is Being Referred
*
Surgery/Orthopedics
Cardiology
Neurology (unavailable through November 2026)
Medical Oncology
Internal Medicine
Preferred Doctor for Referral
(specifying a doctor could impact appointment availability)
Brief Summary of Patient's Current Medical Condition and Purpose of Referral
*
(This information will help us ensure your patient is scheduled with the specialty department that will best address their current medical needs. Please grade any lameness 0-5 and list limbs affected, grade heart murmurs 1-6, list frequency of seizures to help us triage the referral.)
Pertinent Diagnostics or Treatments Performed
*
Please attach a summary of the patient's medical record, lab work results and diagnostic images
*
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