Please Note: We will be closed on Thursday, Nov 27th and Friday, Nov 28th, in observance of Thanksgiving!

We have Rabbit Hemorrhagic Disease vaccines in stock!

Referral Form

Please fill out the form below.

Patient Referral Form

This form is for veterinary referrals only. If you are a pet owner, please see forms under New Clients or Current Clients.

Referring 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). * *

Yes
No, my client will be calling your office

Patient Information

Owner’s Name *

First

Last

Owner’s Phone *

Email *

Pet’s Name *

Pet’s Species/Breed *

Pet’s Sex *

Male
Female
Unknown

Has pet been neutered or spayed? *

Yes
No
Unknown

Pet’s birth date or age *

Medical Details

Name you chief

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

Tentative diagnosis given to client:

Current medications, including strength, frequency, and duration:

Please upload medical records by clicking on the icon below. Please include all radiographs, ultrasound reports, blood test results, etc.

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

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 ask new clients to visit our website at exoticpetclinic.com and fill out our New Client Form. Thank you!

We have Rabbit Hemorrhagic Disease vaccines in stock!

Referral Form

Patient Referral Form

Referring Veterinarian

Patient Information

Medical Details

Contact Us

Questions?

Contact

Hours

Location