Specialty Referral Form

Referring Veterinarian's Information

First Name*

Last Name*

Clinic*

Email*

Would you like to receive VSC's Referring Veterinarian Newsletter?

Yes, please.
No, thank you.

Personal Email*

Client's Information

First Name*

Last Name*

Phone*

Patient's Information

Patient's Name*

Species*

Canine
Feline

Weight (kg)

Breed*

Age*

Sex*

Referral Information

Type*

For outpatient ultrasounds, please use our Ultrasound-only Referral Form.

Interdepartmental referral OK if necessary*

Yes
No

Medical Information

Any size files can also be uploaded below.

Primary Problem(s)*

Pertinent Medical History*

Diagnostic Tests Performed/Results*

Type NONE if applicable.

Current Medication*

Type NONE if applicable.

Previous surgical and/or other procedure(s) and date(s)

Upload Any Size Files (records, labs, radiographs, ultrasounds, MRIs, CTs, etc.)

Please upload a one-year history, current blood work, imaging, and any other relevant information.

Clicking on "select a folder", will only allow the upload of an entire folder and not individual files. IF RECORDS ARE NOT UPLOADED OR RECEIVED WITHIN THE NEXT 48 HOURS, IT WILL RESULT IN CANCELLATION OR RESCHEDULING OF THE APPOINTMENT.

IF CLICKING SUBMIT BUTTON BELOW DOES NOT DISPLAY SUBMISSION SUCCESSFUL, PLEASE SCROLL UP, CORRECT ANY FIELDS HIGHLIGHTED IN RED, AND TRY AGAIN.

Phone

This field is for validation purposes and should be left unchanged.

24 Hour Emergency & Critical Care

Referring Veterinarian's Information

Client's Information

Patient's Information

Referral Information

Medical Information

IF CLICKING SUBMIT BUTTON BELOW DOES NOT DISPLAY SUBMISSION SUCCESSFUL, PLEASE SCROLL UP, CORRECT ANY FIELDS HIGHLIGHTED IN RED, AND TRY AGAIN.

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