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Referring Veterinarians Form

To refer a patient to one of our doctors, please fill out the form below or call us.

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Referring Veterinarians Form

Please fill out this form as completely and accurately as possible.

Date *

Referring Veterinarian *

Clinic Name *

Phone *

Fax

Email *

Client Name *

First

Last

Client Phone *

Patient Name *

Species *

Breed *

Sex *

Male
Female

***Please note: We are doing our best to accommodate and prioritize your cases, we are currently scheduling initial consults within 2-3 weeks. If you feel that this patient needs to be seen sooner, or are not sure if they should see the oncologist or surgeon first, please call to discuss with one of our doctors.

Referral for *

Oncology
Surgery
Both

Do you feel this patient needs to been in *

1 week
2 weeks
1 month

Patient history, lab results, clinical findings, recent treatment, prior surgery, etc *

*Do you need guidance with pre-referral diagnostics or help to keep pet comfortable/stable prior to referral? If yes, please call us.

*For oncology cases, is the client seeking: *

Chemotherapy
Staging
Hospice/End of Life Care

Date of tests selected above

Records/Radiographs, including this form, may be sent to:
Email: [email protected]
Fax: 503-850-4791
Thank you for your referral! Please don't hesitate to contact us if you have any questions, we're happy to help!
Veterinary Cancer & Surgery Specialists

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Referring Veterinarians Form

Referring Veterinarians Form

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