Online Referral Form – Rehabilitation

Name

This field is for validation purposes and should be left unchanged.

EMERGENCY REFFERALS(Required)

PLEASE DO NOT USE THIS FORM FOR EMERGENCY REFERRALS. INSTEAD CALL OUR OFFICE AT 919-489-0615 TO SPEAK DIRECTLY TO A CLINICIAN.

My patient does not need to be referred to the emergency department

Sedation Needed?(Required)

Referring Veterinarian(Required)

First Last

Referring Hospital(Required)

Hospital Phone Number(Required)

Client Name(Required)

First Last

Pet Name(Required)

Client Phone Number(Required)

Species(Required)

Breed(Required)

Age(Required)

Sex(Required)

Reason for Referral(Required)

Findings and Diagnostics Performed(Required)

Radiographs(Required)

Will radiographs be submitted to [email protected] prior to the patient appointment?

Yes

Current Medications(Required)

Additional Comments

Behavioral Concerns or Medications

OPUS Appointment

Our CSR team will reach out to the client within 36 hours of receiving this referral to schedule the OPUS appointment.

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