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
If referring for a CLINICAL TRIAL, please check here:

Service(s) Requested

Cardiology Dental/Community Practice Dermatology Emergency Internal Medicine
Neurology Ophthalmology Surgery Theriogenology Rehabilitation Unsure
Oncology at Animal Cancer Care and Research Center in Roanoke, VA

Client Information

Patient/Animal Information

Referring Veterinarian / Clinic Information

Patient Case History

Attachments / Additional Records

Have additional images or records been sent electronically?
Have additional records been faxed?
Have additional images or records been sent with the client?
Attach Files / Images