Veterinarian Referral Form Referring Hospital* Email* Referring Veterinarian* Client Name* First Last Client Phone*Patient Name* SignalmentSpecies* Date of Birth / Age* Breed* Gender* Male Female Reproductive Status* Intact Altered Weight poundskilogramsPatient HistoryType of Services Requested (consultation, surgery, etc) Presenting Complaint*(If presenting for lameness, please state which limb is lame - thoracic or pelvic, left or right)Onset and Duration of Problem*Current Medications and DosagesOngoing or Additional Medical Conditions Allergies Seizures Cardiac Problems Skin Condition Other Allergy DetailsSeizure DetailsCardiac Problem DetailsSkin Condition DetailsOther DetailsDiagnostic Imaging and Laboratory WorkCheck all that apply Radiographs CT MRI Ultrasound Blood Work Cytology Histopathology Other Imaging / Laboratory Results Drop files here or Select files Max. file size: 5 MB. Δ
