Referral FormReferral Type:Emergency ReferralSpecialty ReferralDownload PDFReferring Veterinary InformationPractice Name:Referring Veterinarian:Practice Phone Number:Practice Fax Number:Please contact in case of dire change in condition or prognosis:Contact Number:Client InformationName:* First Last Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone:Patient InformationName:Species:Breed:Age:Sex:Weight:Referral InformationPresenting 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 reception@lancasterpetemergency.com or sent with your client.CAPTCHA