Patient Referral Forms

Please check the appropriate box within the specific category below for the service for which you are referring.

Specialty:

739 Warren Ave, Phone: 207-878-3121 option 4, Fax: 207-780-0272, Email: specialty@pvesc.com

Cardiology
Internal Medicine, Ultrasound, or Endoscopy
Oncology
Radioactive Iodine Therapy
Neurology
CT/MRI

Dermatology:

2255 Congress Ave, Phone: 207-878-3121 option 3; direct line 207-780-6058, Fax: 207-842-9091, Email: specialty@pvesc.com

Dermatology

Surgery:

739 Warren Ave, Phone: 207-878-3121 option 2, Fax: 207-878-0829, Email: surgery@pvesc.com

Surgery
Sports Medicine and Rehabilitation
CT/MRI
Synovetin OA Treatment

Emergency:

739 Warren Ave, Phone: 207-878-3121, Fax: 207-878-0829, Email: emergency@pvesc.com. Emergency ultrasounds are available on weekends based on emergency clinician recommendations.

Emergency

Please check the box above that corresponds to this referral.

IMPORTANT: Medical Consultations and ultrasounds are completed by appointment with our Internal Medicine Specialists Monday through Friday. These appointments include results and case discussion with the client. Ultrasounds without consultation are completed by appointment with the Radiologist on Saturdays. Please note, Saturday ultrasounds do not include discussion with the client; ultrasound report will be emailed to the referring veterinary office for discussion with the client. Emergency ultrasounds can be completed on weekends on an as needed basis as recommended by the emergency clinician.

Date

Referring Veterinarian:

Hospital/Clinic:

Phone:

Fax:

Email:

Client Information

Name:*

First Last

Phone:*

Address

Street Address Address Line 2 City State ZIP Code

Patient Information

Name:*

Species:*

Breed:

Age:

Sex:

Brief History/Chief Concern:

Tentative Diagnosis:

Current Treatments /Medications:

Procedure(s) Requested:

Histopathology/Cytology Date and Results (please send copy):

Date of most recent blood analysis, including what was run (please send copy):

Date of most recent Heartworm Test/4DX:

Results:

Date of most recent Rabies vaccination:

1 year or 3 year?

Radiographs Taken:

**PLEASE ATTACH ANY LABORATORY ANALYSES PERFORMED THAT ARE PERTINENT TO THE PRESENTING PROBLEM – PLEASE E-MAIL or SEND RADIOGRAPHS WITH OWNERS**

Max. file size: 128 MB.