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Referring veterinarian's name

Referring Hospital's name

Referring Hospital's phone number

Referring Hospital's email

* Desired specialty department * Desired specialty departmentDentistry and oral surgeryInternal medicineOncologySurgery

Please indicate the reasons for the referral

Owner's name

Owner's phone number

Owner's email

Patient's name

* Species * SpeciesCanineFelineOther

Breed

Date of birth/age

* Sex * SexMMNFFS

* Please attach all relevant medical documents UploadPatient file, blood results, other files...Accepted files : jpg, jpeg, jpe, gif, png, bmp, tiff, tif, webp, avif, ico, heic, heif, heics, heifs, asf, asx, wmv, wmx, wm, avi, divx, flv, mov, qt, mpeg, mpg, mpe, mp4, m4v, ogv, webm, mkv, 3gp, 3gpp, 3g2, 3gp2, txt, asc, c, cc, h, srt, csv, tsv, ics, rtx, css, htm, html, vtt, dfxp, mp3, m4a, m4b, aac, ra, ram, wav, x-wav, ogg, oga, flac, mid, midi, wma, wax, mka, rtf, js, pdf, class, tar, zip, gz, gzip, rar, 7z, psd, xcf, doc, pot, pps, ppt, wri, xla, xls, xlt, xlw, mdb, mpp, docx, docm, dotx, dotm, xlsx, xlsm, xlsb, xltx, xltm, xlam, pptx, pptm, ppsx, ppsm, potx, potm, ppam, sldx, sldm, onetoc, onetoc2, onetmp, onepkg, oxps, xps, odt, odp, ods, odg, odc, odb, odf, wp, wpd, key, numbers, pages. Max. file size: 10 MB

Relevant medical history summary: Relevant medical history summary: Yes No

If yes, please specify

Special Request or additional information