Maine Veterinary Referral Center - Referral Form From Vet

On-line Doctor Referral Form / Making an appointment:
• Confirm health records and diagnostic results needed for MVRC appointment
• Let our receptionist know if you will need assistance bringing your pet into the building from your vehicle so that we can be ready to assist you.
• If you or the MVRC anticipates your pet will be admitted for hospitalization, you may want to bring special diets and medications.
Please label all items with your pet’s name.

Health records for MVRC are:
Digitally sent by:
Diagnostic images (Radiographs, CT/MRI images,etc)
Pet owner's name:
Spouse / partner name:
Address:
City / State / Zip:
Home phone #, with area code:
Cell phone #, with area code
Fax, with area code:
Email address:
Pet name:
Pet date of birth:
Species:
Breed:
Sex:
Neutered?:
Date of last rabies vaccination:
Specialty service requested:
Does your pet have any known critical conditions/allergies? If yes, please describe:
Is your pet currently on medication? If so, please list
Additional owner requests, questions or concerns:
History and clinical findings:
Diagnostic tests pending:
If other, please list test:
Primary care veterinarian:
Primary veterinary hospital: