Referrals

Thank for choosing Palm Beach Veterinary Specialists as your partner for emergency, specialty, and advanced care. We sincerely appreciate the opportunity to work with you to care for your patients.

VCA Referral Form
In order to help our veterinary staff accurately assess your patient's current status, we ask that prior to referral; please complete the referral form below.

Download VCA Referral Form

Referral Form

All fields are required unless otherwise stated

Some information is missing. Please see below for details.

Appointment Date

Time

Referring DVM

Referred to Doctor/Dept.

Referring Hospital

Address

Phone

Backline(optional)

Fax (optional)

Services Requested

Complete Specialty Consult (optional)

Contact Preference (optional)

Specific Diagnostics (optional)

Specific Treatment (optional)

If available, please send the following with your client; patient information to include:

Medical Notes/Records
Imaging
Lab Work Results
Treatments, including last time administered
X-Rays
Other

Guardian Details

Name of Client/Agent

Co-Owner (optional)

Main Contact Number

Second Contact Number (optional)

Other (optional)

Address

Patient Details

Patient Name

Species

Breed

Age

Color

Sex

F SF M CM Unknown

Tentative Diagnosis/Chief Complaint

History/Physical Findings (optional)

Treatment (including medications and dosages) (optional)

Special Requests/Comments (optional)

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Some information was missing. Please see above for details.

Referrals

Referral Form

Thank You