Referral Form

Please fill out this form as completely and accurately as possible.

Clinic Name *

Referring Veterinarian *

Referring Veterinarian Email *

Cell Phone (if you want one of our DVMs to contact you) *

Owner's Name *

First

Last

Patient Name *

Age *

Sex *

Breed *

Reason for Referral *

Precautions / Special Considerations / Additional Comments *

Medical Record *

Labwork *

Radiographs *

Medications *

If indicated, do you want us‬ ‭ to discharge your patient… *

Please have client bring a hard copy of all records‬ ‭OR email records to‬‭ info@hcaeh.com‬ OR upload below. *

Upload Records

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Date *

Comment

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Where to Find Us

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Mon-Thur: 6pm – 8am
Fri 2pm – Mon 8am
Holiday Hours – Open 24 hours