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Patient Referral Form

For referring veterinarians: Please complete our Patient Referral Form to facilitate a referral with one of our specialists. A PDF version is available for your convenience. If submitting via PDF, please email to info@uvsonline.com or fax to 518-783-3199.

Patient Referral Form

Outpatient Ultrasound Form
Patient Referral Form
Telemedicine Consult Form
Choose Form*
- Patient Referral Form
- Outpatient Ultrasound Form
If you require a STAT consult, please call UVS to speak directly with the appropriate specialist.
Client Name*
First Last
Client Address*
Street Address Address Line 2 City State ZIP Code
Client Primary Phone*
Client Email
Vet Hospital Information
DVM*
Hospital Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Please include hospital fax number, if available.
Email
An email confirmation will be sent to this address.
Pet Information
Patient Name*
First Last
Breed*
Age*
Weight (kg)*
Sex*
- Male Neutered
- Male Unaltered
- Female Spayed
- Female Unaltered
Referral Information
Consult requested with:*
- Cardiology: Dr. Agnieszka Kent | Dr. Cassidy Sedacca | Dr. Andrew Waxman | Dr. Aaron Wey
- Internal Medicine -- Dr. Sara Arnold
- Neurology -- Dr. Todd Bishop / Dr. Laura Krzykowski/ Dr. Christina Scanlon
- Oncology -- Dr. Ariana Verrilli
- Ophthalmology -- Dr. Christa Corbett
- Rehabilitation -- Dr. Laura Perez
- Surgery -- Dr. Joseph Palamara
- Special Instructions (Please specify below)
Special Instructions, please specify*
Chief Complaint for Referral*
Pertinent Medical History*
Current Medications
Please include drug, strength, dosing instructions and date started (e.g. Benazepril 10mg PO BID started 01.14.17)
Completed Diagnostics:*
Please be sure to include pertinent history and exam notes with all diagnostics.
- CBC
- Chemistry Profile
- Urinalysis
- Thyroid Testing
- HW/Lyme/Ehrlichia/Anaplasma status
- Other Labwork (Please specify below)
- Blood Pressure
- ECG
- Radiographs
- Ultrasound Studies
- CT
- MRI
- Other (Please specify below)
Other Labwork , please specify*
Other, please specify*
Telemedicine Consult
Chief Complaint for Telemedicine Consult*
Please select all that apply*
- ECG
- Radiographs
- Ultrasound
- Other Materials included (Please specify below)
Materials, please specify*
Medical Records
Please submit previous 12 months of medical records.
If unable to upload, please email to info@uvsonline.com OR you may fax to us at 518.783.3199.
Drop files here or

Max. file size: 25 MB.
If you require a STAT consult, please call UVS at 518.783.3198 to speak directly with the appropriate specialist.
Phone
This field is for validation purposes and should be left unchanged.