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 Year200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Requested Service(s) * Emergency (transfer/immediate referral - please call) Critical Care (transfer/immediate referral - please call) Cardiology Diagnostic Imaging Internal Medicine Neurology Oncology Orthopedics Physical Rehabilitation Radiology Reproductive Medicine (Theriogenology) Surgery Other Other Service Patient Should Be Seen * - Select -Within 24 Hours (transfer/emergency)24 to 72 Hours3-7 days> 7 days Radiographs, Medical Records, Lab Results * - Select -Will be faxedClient will bringEmailed/will email (firstname.lastname@example.org)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.