Professional Referrals

If you would like to refer a patient to the veterinarians at Animal Emergency Center in Memphis, please complete and submit the form below. 

Referral Form

To refer a patient, please complete the form below. 

Referring Clinic / Doctor

Clinic Name *

Doctor Name *

Email *

Phone Number for Consultation *

Consultation Details *

Contact me for any changes to the instructions below. Contact me only if you have questions about the case or for major changes.

Pet Owner Information

First Name *

Last Name *

Phone *

Email

Address *

City *

State *

Zip Code *

Patient Information

Pet Name *

Age / Date of Birth *

Species *

Breed *

Sex *

Weight (lb/kg) *

Emergency Information

Presenting Complaint *

Diagnosis / Differentials *

Current Medications, Labratory Findings, Recent Surgery, Other. Please include the time medicine was last given or when treatments were complete. Send radiographs and copy of blood work with owner. *

Instructions for Emergency Doctor. Please include medication doses, route of administration, fluid type and rate. *

Upload any relevant documents

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Next Steps (Please check all that apply) *

Bill us for client charges

Patient is to return to my hospital for continued care

Transfer patient to MVS for workup

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