Referral Form

Please fill out the form below.

Patient Referral Form

This form is to be submitted by a veterinarian.

Doctor Name *

First

Last

Hospital Name *

Email Address *

Phone *

Would you like us to reach out to your client to schedule an appointment? (If urgent, please call us directly). * *

Owner’s Name *

First

Last

Owner’s Phone *

Email *

out Details Additional

Pet’s Name *

Pet’s Species/Breed *

Pet’s Sex *

Has pet been neutered or spayed? *

Pet’s birth date or age *

Current problem (please describe chief complaint, onset, progression, and treatments):

Tentative diagnosis given to client:

Current medications, including strength, frequency, and duration:

Upload medical records

Click or drag files to this area to upload. You can upload up to 4 files.

Please also send medical records including radiographs, ultrasound reports, etc.

Records can also be emailed to info@exoticpetclinic.com.

A referral report will be emailed to you shortly after your client’s visit. If you have another preference, please let us know.

Additional comments

Please direct your client to visit exoticpetclinic.com to submit our new client form to register an account with our hospital. Thank you!