Specialty Appointment Request

Specialty Appointment Request Form

If you are interested in scheduling a consultation with one of our specialists, please fill out our appointment request form below so we can coordinate a referral from your primary care veterinarian. Once we receive a referral from your veterinarian we will connect with you to schedule a convenient time for your pet’s consultation.

Please note, this form is not intended for emergency visits. If your pet is experiencing an emergency, please call LIVS (516) 501-1700 or head to our hospital immediately.
Today's Date*
MM slash DD slash YYYY
Veterinarian Information
Primary Care Veterinarian Name*
Primary Care Practice Name*
Primary Care Practice Phone*
Pet Owner Information
Pet Owner's Name*
Pet Owner's Phone*
Pet Owner's Address*
Street Address Address Line 2 City State ZIP Code
Patient Information
Pet's Name*
Age*
Sex*
Species*
Species (if other, please specify)
Breed
Department You're Requesting an Appointment With*
Reason for Your Appointment Request*
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