Referral Form

Date
Date Format: MM slash DD slash YYYY
Referrring Veterinarian Name
Prefix First Last
RVDM Phone Number
RDVM Fax Number
RVDM Email
Client Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client Phone Number
Client Email
Patient Name
Species
Age
Breed
Sex
Color(s)
Weight
Patient being referred for:
- Second Opinion
- Ultrasound
- Surgery
- Endoscope
Radiograph/Lab Results/Medical History Upload
Please fax or email blood work histopathology/cytology, and radiographs (if digital) in advance of the appointment if possible.
Additional Request from RDVM?
This patient is being referred to the Clarion Animal Hospital for further investigation and treatment of the above condition. In order to avoid duplicating work and expense, please send radiographs and copies of diagnostic tests. When the patient is released from the Clarion Animal Hospital, the client will be sent home with discharge instructions and a summary of their pet’s treatment. The referring veterinarian will be sent this same information in order to keep their hospital’s records up to date. The patient may also be required to return to Clarion Animal Hospital for a follow-up visit to check his/her progress at the doctor’s discretion. Upon request, an estimate can be forwarded to the client.

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