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 & ExoticsCardiologyCritical CareDentistry & Oral SurgeryDermatology & AllergyDiagnostic ImagingInternal MedicineNeurology & NeurosurgeryNutritionOncologyOphthalmologyRehabilitation & FitnessSports MedicineSurgery & OrthopedicsReason 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:*Clinic Name:*Phone:*Fax:E-mail: CLIENT/PATIENT INFORMATIONOwner Name:*Co-owner:Primary Phone Number:*Work Phone:Cell Phone:Pet Name:*Breed:*Sex:*MaleMale - NeuteredFemaleFemale - SpayedAge/DOB:*Weight:MEDICAL RECORDS, PERTINENT LABWORK AND RADIOGRAPHSHave radiographs been taken?*YesNoDate 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 CommentsThis field is for validation purposes and should be left unchanged.