Veterinary Referral Form – Vet Mobile Surgery

This form is intended for use by veterinary professionals only. If you are a pet owner, please reach out to your primary care veterinarian to schedule a consultation with Dr. Eisele for your pet.

Referring Veterinarian Information

Veterinary Hospital:

Referring Veterinarian:

Phone:

Email:

Client/Patient Information

Client Name

Client Phone:

Client Email:

Patient Name:

Species

Breed

Age:

Sex:

Weight (lbs):

Case Information

Please attach copies of any relevant medical records, test results, and radiographs (dcm, pdf, doc, jpeg, png). Links to DICOM images can be entered in the next field. Alternatively, you can email files to info@vetmobilesurgery.com. Please include the patient and owner’s names in the email subject line.

Upload Case History / Relevant Physical Findings:

Drag & Drop Files Here

Browse Files

Link to DICOM images:

Working Diagnosis / Reason for Referral: