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.

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 *

Pet’s Name *

Pet’s Species/Breed *

Pet’s Sex *

after * complaint,

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:

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

Click or drag files to this area 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!