Specialty Referral Form

Facebook

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

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*

SMS Consent

By checking this box, you consent to receive informational text messages from Veterinary Specialty Center at the number provided, including messages sent by the autodialer. Consent is not a condition of purchase. Message & data rates may apply based on your mobile carrier's plan. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. View our Privacy Policy & SMS Disclosure for more information.

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)

Uploading records is temporarily unavailable. Please email all records to help@vetspecialty.com or fax them to 847-808-8900.

This field is hidden when viewing the form

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.

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.

Get in Touch

Quick Links

Business Hours