Veterinarian Referral Form

Referral Instructions

VETERINARIANS: When referring your patient to VEC, please complete this form prior to referral. You may print it and handwrite your entries and fax it to us at fax #860-693-8142, or type directly into the form and click SEND. Pertinent medical records may also be faxed or emailed along with the referral form. Alternately, you may have the pet owner bring the records along with them. If you require assistance, have questions or wish to discuss your patient’s case prior to referral, please call our hospital at 860-693-6992.

Referring Veterinarian/Clinic Information

Referring DVM Name (required)

Your Email (required)

Clinic Name

Address/State/Zip

Phone

Fax

Overnight Phone Number For Fixed-Rate Observation

Patient Information

Patient Name

DOB/Age

Species

Breed

Color

Gender
 Male Female

Altered?
 Yes No

Pet Owner’s Name and Contact Information

Name

Email

Address/State/Zip

Home Phone

Work Phone

Mobile Phone

Patient Case History

Condition of Patient
 Critical Stable

Presenting complaint/chief medical concerns

Reason for referral

Pertinent Medical History (including vaccination history)

Current Diagnostics/Treatments/Medications (including dosages)

Attach a document here with any other pertinent info.

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