Referring Vets

If you are a referring veterinarian, please complete the form below and upload all medical records including patient SOAPs and medical notes, surgery reports, laboratory results (bloodwork, urine testing, cytology, histopathology, etc), radiology reports, and links to images if possible. This will help streamline the referral process and get your patient in for a consultation as soon as possible. Thank you so much for your partnership with us!

Patient Referral

Veterinarian’s First Name(Required)

Veterinarian’s Last Name(Required)

Veterinary Hospital Name(Required)

Veterinary Hospital Email Address(Required)

Veterinary Hospital Phone Number(Required)

Which best describes you?(Required)

Veterinarian

Technician

Front Desk Staff

Other

What is your role?

Patient/Client Information(Required)

Client First Name Client Last Name

Patient First Name

Client Phone Number(Required)

Client Email

Diagnosis (If your patient does not have a definitive diagnosis, list the current problems and/or symptoms here)(Required)

History(Required)

Questions/Comments

Upload Medical Records (Please upload all medical records pertaining to recent diagnosis, including the following)(Required)

-Medical notes
-Bloodwork and urine test results
-Cytology or histopathology reports
-Radiograph images with written radiology report(s) if available
-Abdominal ultrasound report(s) if available (images not necessary if too difficult to upload)
-Other outside laboratory results
-Any other biopsy/cytology reports if diagnosed with cancer in the past

Drop files here or

Accepted file types: jpg, png, pdf, docx, Max. file size: 20 MB.

Would you like us to contact your client directly to set up a consultation? If answering yes, please let your client know that we will be contacting them.(Required)

Yes

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Complete the Sentence: what goes up must come...

Referring Vets

Patient Referral

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