Veterinarian Referral Form

You may download and fill out our PDF Referral Form and fax it to LIVS at 516-501-1169, or complete our online form below.

Today's Date*
MM slash DD slash YYYY
Referring Veterinarian Information
Referring Veterinarian Name*
Referring Practice Name*
Referring Practice Phone*
Referring Practice Fax
Referring Practice Email
Pet Owner Information
Owner's Name*
Owner's Home Phone*
Owner's Work Phone
Owner's Mobile Phone
Owner's Address
Street Address Address Line 2 City State ZIP Code
Patient Information
Name*
Age*
Sex*
Weight*
Breed*
Presenting Problem*
Past Pertinent History*
Diagnostic Tests Performed or Pending (please upload a copy of completed tests and note the status of pending tests)*
Completed Tests
Max. file size: 50 MB.
Current treatment(s) and medication(s) administered if known*
Additional Comments

LIVS Referral Form