RDVM Referral Online Application Form

If you are a veterinarian who would like to refer a patient to our center, please fill out the form below with all available 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, pdf, Max. file size: 8 MB.
      Please upload files associated with this referral. Accepted file types: PDF, JPEG, PNG, DOC, DOCX
    • 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