Patient Referral Form

Thank you for considering Dogwood Veterinary Specialty and Emergency. Please fill out the information below to expedite the referral process.

Referring To

For which service are you referring the patient to?

Cardiology
Critical Care
Emergency
Internal Medicine
Oncology
Surgery

Referring Clinic

Name of your Clinic or Hospital

Referring Doctor

Name of the referring veterinarian

Doctor Contact Method

What is the best way to reach you?

Email
Phone
Text

Client Name

Pet Owner Full Name

Client Contact Method

What is the best way to reach the customer?

Email
Phone
Text

Patient Name

Pet Full Name

Species

Breed

Weight (pounds)

Sex

Spayed/Neutered

Date of Birth

Primary Concern

Reason for referral

{name}

Medical Record

Please send Doctor's notes, records, lab-work, and imaging (JPG or DICOM format) prior to the patient's arrival or appointment, so we can make the most of their visit with us. Emergency: FrontDesk@Dogwood.Vet Specialty: Referrals@Dogwood.Vet

Attach file

Drop files here

Estimate Provided

Has an estimate been discussed with the owner? If yes, please let us know the estimate provided

Do not submit passwords through this form. Report malicious form

Alert