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Request a Consultation / Make a Referral
This form is only to be used by veterinarians and their teams. If you are a potential client, please call the clinic to schedule an appointment.
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33%
Are you making a referral or requesting a consultation?
Consultation (Vet to vet conversation regarding case)
Referral (We will call your client to schedule an appointment)
Which service are you requesting this be forwarded to?
*
Oncology
Ophthalmology (Currently booking out 4-5 months)
Neurology
Surgery
Internal Medicine
Level of Severity
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1. Urgent (LSA, MCT [rapidly growing], oral masses, osteosarcoma, lymphoblastic leukemia, insulinoma [symptomatic], hemangiosarcoma)
2. Intermediate to Stable (STS, anything larger than a half dollar already, anything ulcerated or rapidly growing, pulmonary masses, insulinoma (asymptomatic), hemangiosarcoma (surgically removed), adrenal tumors, thyroid carcinoma, CLL, apocrine gland adenocarcinoma of the anal sac, lipoma, undiagnosed stable skin masses, canine mammary gland tumor, myxosarcoma)
Patient Information
Pet Name
Age
Sex
Male
Female
Altered
Breed
Weight (Specify lbs or kgs)
Pet Parent Information
Client Name
Client Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
Email
Referring Veterinarian Information
Doctor's Name
Clinic
Clinic Phone
Clinic Fax
Clinic Email
Dr. Email
Preferred Method of Communication
Phone
Fax
Email
All
Additional Information
Reason for Referral
Patient History
Physical Exam Findings
Previous Diagnostics
Please upload images/copies of all labs or send with owner
Drop files here or
Select files
Accepted file types: jpg, png, pdf, doc, xls, Max. file size: 5 MB, Max. files: 10.
Medication/Response
Comments
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