Veterinary Referral Form | High Five Paws

Veterinary Clinic Name

Please enter the name of your clinic.

This field is required.

Veterinarian’s Name

Enter the name of the referring veterinarian.

This field is required.

Veterinarian’s Email

Please provide a valid email address for communication.

This field is required.

Veterinary Clinic Phone Number

Enter the phone number for your clinic.

This field is required.

Patient’s Name

Input the name of the dog being referred.

This field is required.

Patient’s Date of Birth/Age

What is the dog’s date of birth or age?

This field is required.

Patient’s Breed

What breed is the dog being referred?

This field is required.

Patient’s Sex

What sex is the dog being referred? Is it entire or desexed?

Female Entire

Male entire

Female Desexed

Male Desexed

Reason for Referral

Please describe the reason for referral including any diagnosis and specific needs.

This field is required.

Previous Treatments

List any previous treatments or therapies received by the dog.

Owner’s Name

Who is the owner of the dog being referred?

This field is required.

Owner’s Contact Information

Provide the owner’s email or phone number for follow-up.

This field is required.