Have you called CVRC about this referral? * Yes No To whom did you speak? Referring Veterinarian Information Veterinary Hospital * Doctor's Name * Address Country - None -United States Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * How would you prefer to be contacted on this case? * - Select -PhoneFaxEmail Would you prefer to be contacted after hours on this case? * Yes No Client/Patient Information Client Name (First & Last) * Client Phone * Patient Name * Species * - Select -CanineFelineOther Other Species Breed * Sex * Male Male, neutered Female Female, spayed Unknown / Other DOB * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Requested Service(s) * Emergency (transfer/immediate referral - please call) Critical Care (transfer/immediate referral - please call) Cardiology Internal Medicine Neurology Oncology Orthopedics Physical Rehabilitation Surgery Behavior Other Other Service Patient Should Be Seen * - Select -Within 24 Hours (transfer/emergency)2-5 Days (M-F)5-10 Days (M-F)> 10 Days (M-F) Owner Contact * Pet owner transferring/en route to CVRC (**please call to notify CVRC**) Pet owner will contact CVRC to schedule (For non-emergency/transfer requests) Please contact the owner to schedule (For non-emergency/transfer requests) Radiographs, Medical Records, Lab Results * - Select -Will be faxedClient will bringEmailed/will email ([email protected])Uploaded/AttachedNone being transferred Upload Records or Images Upload Records or Images Upload Records or Images Upload Records or Images Upload Records or Images Upload Records or Images Reason for Referral Past Relevant History Previous/Current Treatment(s) or Medication(s) Expectations For This Case * Consult only. Please return to my office for diagnostic testing and treatment. Please manage the diagnostic testing and treatment at CVRC. feed me To prevent automated spam submissions leave this field empty.