Central Pennsylvania Veterinary Emergency Treatment Services
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1522 Martin Street
State College, PA 16803
(814) 237-4670
Toll free (866) 694-7844
Fax (814) 237-4646
REFERRAL INFORMATION FORM FOR NIGHT AND WEEKEND HOSPITALIZATION
Referring Practice:____________________________________________________________________
Referring Veterinarian:________________________________________________________________
Street:________________________________________________________________________________
City/State/Zip:_________________________________________________________________________
Telephone:____________________________________________________________________________
Fax:___________________________________________________________________________________
Email:_________________________________________________________________________________
Owner's name:_________________________________________________________________________
Owner's telephone/cell:________________________________________________________________
Secondary contact name:______________________________________________________________
Secondary contact telephone/cell:______________________________________________________
Owner's street address:________________________________________________________________
Owner's city/state/zip:__________________________________________________________________
Patient name:__________________________________________________________________________
Species:________________________________ Breed:________________________________________
Sex:_______________ Neutered? Yes______ No______
Age:__________________ Weight _______________lbs or ______________kgs
Rabies vaccination current? Yes______ No______
Other vaccinations current? Yes______ No______
Please list vaccinations: _______________________________________________________________
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Reason for patient referral:_____________________________________________________________
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Pertinent patient history:______________________________________________________________
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Laboratory results (please fax all available bloodwork, cytology/biopsy reports; and
send radiographs with owner if possible)
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Medication (dosage/duration/response):____________________________________________
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Remarks or requests:_____________________________________________________________
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