Online Vet Referral Form - Gulf Coast Veterinary Specialists

Date

Status of appoinment*

Please select the service needed*

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?

Yes
No

Referring Clinic Name*

Primary Phone*

Cell Phone

Fax

Email*

Would you like to be contacted if this patient needs to be transferred to another GCVS department?

Yes, please contact me prior to making an interdepartmental transfer
No, please proceed with interdepartmental transfer.

Client/Patient Information

Owner Name*

Co-owner Name

Primary Phone Number*

Work Phone Number

Cell Phone

Pet Name*

Species

Cat
Dog

Sex

Breed*

Age or Approx. DOB*

Weight*

Color*

Potentially Infectious

Yes
No

Fractious/Aggressive

Yes
No

Rabies Last Date

Rabies Tag Number

Other Vaccines Current

Yes
No

Vaccine Comments

Medical Reason for No Vaccines

Yes
No

If yes, please explain.

Medical records, pertinent lab work and radiographs.

Have radiographs been taken?*

Yes
No
Unknown

Date of study

Have medical records, lab work, and/or radiographs*

Please email, fax or send copies of radiographs with the owner.

Been Faxed
Emailed
Owner Bringing

Brief History & Primary Complaint

Tentative Diagnosis

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

CAPTCHA

Online Referral Form

Client/Patient Information

Medical records, pertinent lab work and radiographs.