Veterinary Referral Form

The TVSC team is committed to providing excellent surgical care for pets while providing you with outstanding customer service. Please complete the patient intake form below, and we will be back in touch shortly.

Referring Hospital:

Referring Veterinarian:

Hospital Phone:

Hospital Email:

Owner Name:

Owner Phone:

Alternate Owner Phone:

Owner Email Address:

Owner Mailing Address:

Pet Name:

Age (years, months) and DOB (mm/dd/yyyy):

Weight (in pounds):

Color:

Species:

Breed:

Sex:

Date when most recent rabies vaccine given:

Duration of rabies vaccine:

Pet insurance provider (leave blank if none)

Please describe the current problem/diagnosis for which you are referring the patient:

Please list any medications the patient is currently receiving. If the patient has received Librela, when was the last dose?:

Please include a summary of past medical/surgical problems and information about any allergies or adverse medication reactions the patient has had in the past. (Note: TVSC does not need the entire medical record):

Has this pet been evaluated for this problem at another veterinary hospital? If yes, where?

Other Hospital's Email:

Temperament Notes:

Upload Files (radiographs, radiology report, histopathology report):