Emergency Referral Form

Please complete this form to provide us the information needed to provide your pet’s treatment.

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Referral Information

Referring Doctor*

Referring Hospital

Phone*

Email*

Prefer to be contacted by:*

Phone

Do you want to be called about this patient? **

Phone

If not, the doctor on duty will treat as s/he feels appropriate.

Pet Owner Information

Owner:**

First* Last*

Client Email Address*

Client Phone*

Address:**

Street* City* State* Zip Code*

Patient Information

Pet's Name

Breed

Color

Weight

Age

Sex

Spayed/Neutered?

Allergic Reactions

Presenting Complaint:

Physical Exam:

Laboratory Test/Special Procedures:

Medications

Medication Given

How Much?

Time Given

Click the '+' sign to list more medications.

Recommendations for Treatment Plan:

Please attach any related radiographs or lab work

Drop files here or

Max. file size: 15 MB.

Please inform clients of the following:

1. At EVS, they will be given an itemized estimate and asked to leave a deposit of the low end of the estimate.

2. Remaining fees are due and payable when the patient leaves EVS. We accept cash, all major credit cards, Scratchpay, and Care Credit.

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