Veterinary Teaching Hospital Referral Form

Veterinary Teaching Hospital
245 Duck Pond Drive
Blacksburg, VA 24061
Email: vthpatientservices@vt.edu
Phone: 540-231-4621
Fax: 540-231-9354

Download Form

If referring for a CLINICAL TRIAL, please check here:

Service(s) Requested

Cardiology Dermatology Emergency Internal Medicine

Oncology at Animal Cancer Care and Research Center in Roanoke, VA

Client Information

First Name

Middle Initial

Last Name

Street Address

City

State

Zip Code

Home Phone

Mobile Phone

Patient/Animal Information

Patient Name

Species

Breed

Color

Age years months

Gender

Reproduction Status

Weight lbs kgs

Referring Veterinarian / Clinic Information

Veterinarian Name

Practice Name

Street Address

City

State

Zip Code

Phone

Fax

Best Call Time

Patient Case History

Patient Condition

Rabies Vaccination Date

DHLPP Vaccination Date

FDV-FVRCP Vaccination Date

Other Vaccinations

Reason for Referral

Current Treatments & Medications

Diagnostics & Procedures

Medical History/Clinical Signs

Attachments / Additional Records

Have additional images or records been sent electronically?

Yes No

Have additional records been faxed?

Yes No

Have additional images or records been sent with the client?

Yes No

Attach Files / Images

For Dental Referrals, has pre-anesthetic bloodwork been performed?

Yes No