980-580-7700
contact@bedrockvet.com
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Referral Form
Thank you for trusting us with your patients!
Please note: This form should only be filled out by a veterinary team member.
One of our CSRs will be in touch with your client shortly.
Type of Referral
(Required)
Standard
Urgent
(If Urgent,
Please submit this form and call our Admissions Department to initiate your urgent referral at 980-580-7700.)
Exact Reason for Referral (Ex: Right CCL Tear, Left Rear Tibia Fracture, etc.)
(Required)
Clinic Name:
(Required)
Clinic Phone Number:
(Required)
Referring Veterinarian After-Hours Phone Number:
Primary Care DVM:
(Required)
Clinic Email Address:
(Required)
Client Name:
(Required)
First
Last
Client Phone Number:
(Required)
Patient Name:
Species
(Required)
Canine
Feline
Other
If other, please specify:
(Required)
Patient demeanor?
(Required)
Friendly
Caution
Requires Muzzle
Rabies vaccine up to date?
(Required)
Yes
No
Is the patient up to date on other vaccines?
(Required)
Yes
No
Blood work completed within the last 3 months?
(Required)
Yes
No
Radiographs completed?
(Required)
Yes
No
Any Heart Murmur?
(Required)
Yes
No
Any health concerns we should know about before anesthesia or surgery?
(Required)
Yes
No
If yes, please explain:
(Required)
Summary of Doctor's Exams:
(Required)
Relevant Medications (e.g., NSAIDs, steroids):
(Required)
Upload Medical Record & Diagnostics:
Drop files here or
Select files
Max. file size: 256 MB.
Date
(Required)
MM slash DD slash YYYY
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Comments
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Info on CCL Tears
