Patient Referral Form:
For Vets

Use this form to refer a patient for a comprehensive ophthalmology exam. Share the pet’s history, current findings, and any imaging you’d like our team to review. We’ll coordinate scheduling directly with the owner and send a written summary back after the consult.

All referrals must be sent with complete medical records.

This form is for vets and veterinary teams ONLY.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Referral Type*

Referral Doctor Preference*

Referring Veterinary Clinic*

Referring Veterinarian*

Contact Phone Number for Veterinarian*

Veterinarian Email*

Client Name (First Last)*

Client’s Phone Number*

Pet’s Name*

Patient’s Signalment (Age, Sex, Breed)*

Reason for Visit / Diagnosis (e.g. indolent ulcer)*

Brief Summary of Ophthalmic Exam*

Treatment & Medications*

Pertinent OTHER Conditions (e.g. Diabetes mellitus)

Representative completing this form*

If you have your pet’s medical files, please upload them below:

Drop files here or

Max. file size: 49 MB.

Patient Referral Form: For Vets

Patient Referral Form:
For Vets