Hospital Information

Hospital Name *

Hospital Address *

Address Line 1

Address Line 2

City

State

Zip Code

Hospital Phone Number *

Regular Client at Your Hospital? *

Yes
No

Hospital Fax Number

Hospital Email

Referring Veterinarian *

First

Last

Client Information

Client Name *

First

Last

Client Phone Number (with area code) *

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client Email

Pet Information

Pet Name *

Breed *

Species *

Cat
Dog

Sex *

Male
Neutered Male
Female
Spayed Female

Date of Birth *

Is this patient a Caution? *

Yes
No

Referral Information

Significant/Previous Medical History (Including Allergies) *

Current Medications *

Reason for referral (please include any recent surgical procedures, treatments, and diagnoses)

Has the patient had bloodwork, x-ray's, or other diagnostics recently (related to the case)? Please attach anything related to this case at the end of the consult form or send results with the client at time of consult.

Has the patient had bloodwork or x-ray's recently (related to the case)? Please email any diagnostics related to this case to villagevethamburg@gmail.com or send results with the client at time of consult.

Last date of Rabies vaccine? *

Goals for patient?

Medical Records

Please be sure to include all medical notes pertinent to the concern. If the concern has been ongoing for 6 months, please send everything for 6 months. If the concern has been ongoing for 6 years, please send everything for 6 years.

If you have completed any lab work or other test results, please attach here:

This may include:

• CBC

• Chemistry

• Urinalysis

• Thyroid Testing

• Pathology/Cytology

• HW/Lyme/Ehrlichia/Anaplamsa

• ECG

• Blood Pressure

• Surgery Reports Related to Concern

• Radiographs

• Ultrasound Studies

• CT

• MRI

• Other

Medical Records - Upload

Click or drag files to this area to upload. You can upload up to 14 files.

FOR VETS- Canine Rehabilitation & Rehabilitation Referral Form

Online Forms

Please note: Have clients call to schedule an appointment if you are sending in a referral.

Hospital Information

Client Information

Pet Information

Referral Information

Medical Records

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Hamburg, New York.

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