Referring Veterinarian Information

Veterinarian:

Hospital:

Client Information

Client:

Address:

Apartment Number:

City:

State:

ZIP:

Home Phone:

Work Phone:

Cell Phone:

Patient Information

Pet's Name:

Age:

Breed:

Sex:

M F MN FS

Rabies Vaccination History :

History:

Diagnostics performed:

Treatments performed:

Current medications:

Concurrent/long term medical conditions:

Additional comments:

As the primary Veterinarian, I would like to be (please check all that apply):

Phoned after examination
Phoned after surgery/procedure

Responsible for follow-up care

Referred to:

Surgery Service

Emergency Service

ETA:

Please have your client contact LVSEH to schedule an appointment at their earliest convenience or, in case of an Emergency Referral, please call or indicate an estimated time of arrival.

Please send us all recent lab results, radiographs and ultrasound images via e-mail, fax, mail, or with the pet owner. Thank you for allowing us to serve you and your clients.

* = required fields

Click here to download form as .pdf file or fill out online form shown below.

Referring Veterinarian Information

Client Information

Patient Information

As the primary Veterinarian, I would like to be (please check all that apply):

© 2008 Lakeshore Veterinary Surgical Specialists Port Washington (262) 268-7800 Racine (262) 554-5344

Click here to download form as .pdf file
or fill out online form shown below.