1. Referring veterinarian / clinic

Preferred contact method

2. Patient identification

Sex

3. Owner / Responsible party

4. Presenting problem / reason for referral

5. Relevant history & chronic conditions

6. Diagnostics

Diagnostics already performed
Attachments sent
One file only.
50 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

7. Referral Urgency

Urgency
Checklist

Scheduling Information

New Client Deposit: A $60 scheduling deposit is required for all new clients when the appointment is scheduled. The deposit will be applied to the patient's appointment charges. Please inform the client of this requirement prior to referral.

Scheduling process: Upon receipt of this completed form and all pertinent records, a member of the Heritage Veterinary Care team will contact the client to schedule an appointment.

Preferred method of communication

Email to: [email protected]

Secondary method: Fax to 740-937-2010

For any questions or concerns, please contact our referral specialist

Brianne Smith (740) 937-2000

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