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Doctor Referral Form

Referral Process:

Please note that all medical notes must be sent along with this referral form, and all areas of this referral form must be filled out. Areas left blank, or a lack of medical records, may slow the process of your referral application or it may be declined. Along with submitting this form and the medical records, a veterinarian or RVT involved with the case must call PVEH and speak with one of our veterinarians or RVTs regarding the referral. These steps must be completed prior to the patient arriving at our facility to ensure a smooth transition of care.

Thank you for your understanding.

  • Referring Veterinarian Information:

  • Client Information:

  • Patient Information:

  • Reason for Referral:

  • (Financial limits, insurance etc)

  • Diagnostics Completed:

    (Please summarize any completed diagnostics below, and ensure all diagnostic results are sent to PVEH with this referral form).
  • Drop files here or

  • List of Current Medications and Treatment:

  • (Type of fluids, route, amount)
  • (Type, dose, route, time) Example: Metacam 5mg/mL, 0.1mg/kg, SQ, 4:30pm on day of transfer
  • (Surgical procedures, u-cath unblocking, etc)
  • (Eg. Cushing’s that is being managed, Atopy that is being managed, Seizure disorder etc)

  • Preventative Care History:

  • Would the referring vet or clinic like updates on this patient while they are in our care if time permits?

  • NOTE:

    Records will be sent back to the referring clinic within 72 hours of the patient leaving our facility.

  • Please note that all medical notes should be sent with the referral form, and all areas of the referral form should be filled out. Areas left blank may slow the process of your referral application.