RDVM Referral Online Application Form

Starting in April 2023, we request that you send referrals through the rVetlink portal.

Please send all referrals through rVetlink portal, if your clinic is not already signed-up, contact our office at (850)477-3914 for more information.

 

RVDM Referral Form

  • Please enter the referring Veterinary Doctor's name.
  • Please provide the referring Veterinary Hospital name.
  • Please provide the referring veterinarian's phone number.
    Please let us know if this is for a routine or urgent referral to VERC.
  • Please provide the first and last name of the pet owner/client.
  • Please provide the client's primary phone number.
  • Please indicate whether this is a home phone number/land line or a mobile phone number.
  • Please provide an alternate phone number for the client.
  • Please indicate whether this is a home phone number/land line or a mobile phone number.
    Please select all applicable reasons for your referral.
  • Please provide the patient's name.
  • Please provide the patient's species.
  • Please provide the patient's name.
    Please select the patient's sex.
  • Please provide the patient's weight.
  • Please provide the patient's age.
  • Please describe the presenting problem.
  • Please list any diagnostics performed on the patient. Email imaging, records, etc. to [email protected]
  • Please list any surgical procedures performed on the patient.
  • Please list any treatments given to the patient. Be sure to include all medications, route and time of administration and mg administered.
  • Please provide any additional information or findings.
  • Drop files here or
    Accepted file types: pdf, jpg, png, docx, doc, Max. file size: 8 MB.
    • This field is for validation purposes and should be left unchanged.

    To submit additional patient information, please download and fill out the forms listed below:

    VERC Client Medication Acquisition Form