Referral Form

Emergency Referral Specialty Referral

Referring Veterinary Information

Practice Name:

Referring Veterinarian:

Practice Phone Number:

Practice Fax Number:

Please contact in case of dire change in condition or prognosis:

Contact Number:


Client Information

Name:

Address:

Telephone:


Patient Information

Name:

Species:

Breed:

Age:

Sex:

Weight:


Referral Information

Presenting Complaint:

Duration of Complaint:

Relevant History and Treatment:

Provisional Diagnosis:

Provisional Prognosis:


Please include all recent blood work, lab findings, x-rays and current medications to minimize repeat testing and lab work. X-rays may be e-mailed to info@lancasterpetemergency.com or sent with your client.