A Variety of Specialities Under One Roof

SNHVRH Online Referral Form

* are required

Referring Veterinarian Information

Referring Doctor*

Hospital Name*




Hospital Address*

Best Time to Call*

Preferred Method of Contact*

Patient Information

Owner's Name*


Owner's Address

Pet's Name*



Sex (select one)*

Date of Birth*

Vaccination History* (select one)

If you have selected OTHER, please describe.

Any Allergies or Precautions?*

If you have selected YES, please explain

Any History/Pre-existing conditions (including surgical procedures and dates)*

If you have selected YES, please explain

Any Medications, Medical Supplements, Diet Changes or other Treatments?*

If you have selected YES, please list with dates

Reason for Referral/Diagnosis*

Please summarize the pertinent medical history and reason for referral by completing the form below.

Please select the department(s) you are requesting a consult with*

Diagnostics Performed/Pertinent Results

Expectations for this referral and any estimates given to client

Special Requests/Comments

Upload Medical Records

We also request that the patient's complete medical record (via attachment, fax or email) is sent ahead of the patient consultation, so that the specialist has ample time to review it. Please include any lab work and/or imaging studies, in addition to this referral form.