Patient Referral Form

Please complete the patient referral form and submit along with any relevant medical records. A member of our team will contact you shortly to facilitate further communication and expedite your patient’s care.

If you need additional assistance, have questions or would like to discuss your patient’s care prior to referral please contact us at 203-929-8600.

Prefer to email or fax in your form?
Please download and email or fax it to us at 203-944-9754

Contact Information

Referring DVM*

Referred to Doctor/Department*

Referring Hospital

Address*

Email*

Phone Number*

Other (Backline, Fax)

Services Requested

Complete Specialty Consult

Contact Preference

Specific Diagnostic

Specific Treatment

If available,

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

Guardian Information

Name of Client/Agent*

Co-Owner

Main Contact Number*

Second Contact Number

Email*

Address*

Patient Information

Patient Name*

Species*

Breed*

Age*

Color*

Comments

We respect your privacy and will not share your information with other parties. For more information, see the Privacy Policy.