Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018 I am referring this case to the following service: Department Referring to * Cardiology Critical Care Dermatology Dentistry Emergency Internal Medicine Neurology Medical Oncology Ophthalmology PetsDx (MRI/CT) Radiation Oncology Rehabilitation Surgery Surgical Radiographic Consultation Urgent? Is this referral due to a life-threatening injury/illness? * Not urgent Urgent Referring Veterinarian Details Referring Veterinarian * Practice * Address * Telephone * Fax Owner Details Owner Name * Address 1 * City, State, ZIP * Home Phone * Work/Cell Phone Email Address Patient Details Patient Name * Species * Breed Sex * - Select -MaleFemale Neutered? * - Select -YesNo Age Weight (in lbs.) Vaccine Status Referral Details Reason for Referral * Please give a brief summary of the patient's history/need for referral * Lab Results Comments (upload bloodwork below or fax to 412-366-3489. Please send X-Rays with owner.) * Lab Results File (Upload bloodwork as pdf, doc, docx, jpg, png or gif) Medications (Dosage/Duration/Response) Remarks or Requests Please discuss the cost of specialty care with your client prior to referral. A tentative estimate will be provided when they call to make an appointment.