GCVS Referral Form This form may only be submitted by a licensed veterinarian. Date* MM DD YYYY Status of appointment*ImmediatelyThis WeekNon-EmergencyPlease select the service needed:*Avian and ExoticsCardiologyCritical CareDentistry and Oral SurgeryDermatology and AllergyDiagnostic ImagingInternal MedicineNeurology and NeurosurgeryNutritionOncologyOphthalmologyRehabilitation and FitnessSports MedicineSurgery and OrthopedicsIf you are attempting to submit a referral for Critical Care, please call 713.693.1155. Critical Care referrals may not be submitted online. Reason For Referral*Rehabilitation and Fitness:As the attending veterinarian, I have determined that rehabilitation will not likely be harmful to the patient.Specified Doctor (optional):Referring Doctor:*Are you a relief vet?YesNoIf so, what is your main clinic?Clinic Name:*Primary Phone:*Cell Phone:Fax:E-mail: CLIENT/PATIENT INFORMATIONOwner Name:*Co-owner:Primary Phone Number:*Work Phone:Cell Phone:Pet Name:*Canine/FelineCanineFelineOtherBreed:*Sex:*MaleMale - NeuteredFemaleFemale - SpayedAge/DOB:*Weight:Color:Potentially InfectiousYesNoFractious/AggresiveYesNoRabies Last Date (mm/dd/yyyy) Rabies Tag Number:Other Vaccines CurrentYesNoVaccine CommentsMedical Reason for No VaccinesYesNoIf yes, please explain:MEDICAL RECORDS, PERTINENT LABWORK AND RADIOGRAPHSHave radiographs been taken?*YesNoUnkownDate of study:Have medical records, lab work, and/or radiographs:*Been FaxedE-MailedOwner BringingBrief History & Primary Complaint:Tentative Diagnosis:Please email, fax or send copies of radiographs with the owner.Attach Files, Records, Data here**Please send current lab work, biopsy reports, and medical records with this form. You may select and upload multiple files at once, or attach a single .zip file. We appreciate the opportunity to work with your patients and we look forward to supporting the relationship you have with them. Drop files here or Accepted file types: zip, jpg, bit, docx, gif, png, pdf, bmp, dcm, doc, xls, xlsx. NameThis field is for validation purposes and should be left unchanged.