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Veterinary Referral Form

Referral to a specialist or emergency hospital

Referral

Referring veterinarianPhoneEmailReferred to (hospital)Service / specialistDate

Urgency

Emergency: todayUrgent: within a weekRoutine

Client / ownerPhoneEmail

Patient nameSpeciesBreedAge / DOBSex / neuter statusWeightkg / lbPatient ID

Reason for referralHistory and problem list

Diagnostics done and key resultsTreatment given (including before transfer)My question for the specialist

Referring veterinarian signature

Printed nameDate