VSS Specialty Department Referral Form
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Email *
Please use this form for urgent or elective cases only. Any EMERGENCY cases should be transferred via phone as usual.
Referring Veterinarian *
Referring Clinic/Hospital *
Client First & Last Names *
Client Phone Number *
Note: Please provide us with your client's email address so that we may notify them of your referral for their pet and our timeline for calling to schedule an appointment.
Client Email Address *
Patient Name *
Patient Age *
Patient Sex *
Patient Species *
Patient Breed *
Brief summary of the patient's presenting complaint/diagnosis *
Note: This summary does not satisfy our request for records. Please be sure your patient's pertinent medical record is sent as well.
Any diagnostics/treatments performed
Current medications
Is this case URGENT or ELECTIVE? *
Additional comments
Service to which patient is being referred *
Required
Preferred doctor for referral (specifying a doctor could impact appointment availability)
FAX (636-527-0812) or EMAIL (reception@vssstl.com) lab work and a summary of the medical record for review. You may email images to reception@vssstl.com or transmit to the VSS Database via DICOM.
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