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Endoscopy Referral Form

This form must be completed by the referring veterinarian, and submitted via email to info@phasesvetemerg.com. Our team will review the referral and contact you to let you know whether it has been accepted. We will then contact your client directly to schedule their scope. Following their scope, the report will be sent back to your clinic for you to share with your clients, unless they have been fully referred into our care through our emergency department. The form must be filled out IN FULL, to avoid any delays in the referral process. Thank you.

  • Referring Veterinary Information:

  • Client/Patient Information:

    *If emergent and/or patient is already on route to the hospital, an emergency referral form needs to be completed and our team must be called.
  • (Include dosage, frequency, dates started, include all medication pet is currently taking including supplements, holistic therapy etc.)