Referral Form

Level of Urgency

Routine Procedure

PRIORITY Procedure

Cold Laser Therapy

Behavior Consultation

Referring Hospital Information

Date of Referral

Clinic Phone Number

Referring Doctor's Email

Reason for Referral & Diagnosis

What Surgery needs to be performed? Please, include any other important information.

Additional Comments

Client Information

Client First & Last Name

Client Phone Number

Client Email

Client Address (City, State, Zip)

Patient Name

Patient's Age or DOB

Sex/ Altered

Male

Female

Altered

Intact

Species

Breed

Color

Patient Temperament

Current Medications/ Supplements

Include Medication, Dose, Frequency

Attach Medical Records

Please Include ALL relevant medical records and diagnostic tests (labs, imaging, etc) performed. Include patient vaccination record, if available.

We will contact the client within 48-72 hours. If marked Urgent we will contact the client sooner.

We are Open Monday thru Friday 8:15AM to 5:00PM