Vet Referral Form

FOR VETERINARIAN USE ONLY!

A referral is preferred when scheduling your client to ensure we can meet the needs of you and your client. Please choose between an in-practice referral and a professional medical review based on the needs of you and your client.

Please Note for those clients seeking a Professional Medical Record Review (Distant/Virtual Care):

We are unable to establish a valid veterinarian-patient-client-relationship (VPCR) without a physical exam, therefore we will be communicating directly with you, the referring veterinarian. Any suggested supplements or herbs can be purchased directly through our online apothecary if needed, however, for any prescription supplement that is recommended, we will defer to you for Rx authorization and assistance. Referring veterinarians are welcomed to call Dr. Pope at the practice anytime Monday-Thursday between 10 am-6 pm EST. She will always make herself available to assist with these patients if needed.

This referral is for:*
- In-Practice Care
- Distant/Virtual Care
Name*
First Last
Veterinary Practice*
Doctor E-mail*
Doctor Phone*
Extension*
How would you like to be contacted?*
- Phone
- Email
Your Client's Name*
First Last
Your Patient's Name*
Patient Species*
- Dog
- Cat
- Other
What is the patient being referred for?*
Is this patient being referred for an integrative diet plan?
- No
- Yes
Please provide patient's weight
Please provide patient's body condition
Please provide patient's muscle score
Please provide a brief summary of the patient's medical history and relevant diagnostics:*
Please attach any relevant records or diagnostics for this patient:
Drop files here or

Max. file size: 50 MB.
Do you feel that this pet will live longer than three months?*
Additional Notes (feel free to include any information about client needs or specific goals):
I have referred this patient to Dr. Kendra Pope.
Signature*
Date*
MM slash DD slash YYYY
Please Note:
We are unable to establish a valid veterinarian-patient-client-relationship (VPCR) without a physical exam, therefore we will be communicating directly with you, the referring veterinarian. Any suggested supplements or herbs can be purchased directly through our online apothecary if needed, however, for any prescription supplement that is recommended, we will defer to you for Rx authorization and assistance. Referring veterinarians are welcomed to call Dr. Pope at the practice anytime Monday-Thursday between 10 am-6 pm EST. She will always make herself available to assist with these patients if needed.
Please have all medical records sent to:
Email: [email protected]
Fax: 732-852-2483
CAPTCHA
File
Max. file size: 50 MB.

Vet Referral Form

FOR VETERINARIAN USE ONLY!

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