Patient Referral Form

This form can also be downloaded by clicking here if you would rather print it out and fax it to us at (719) 564-0514 or you can e-mail it to us at [email protected]

Please call us if you have any questions regarding your patient’s referral!

Internal Medicine Referral Form

This form is for referring primary veterinarians to fill out and submit to our Internal Medicine Service so that we can begin to schedule an appointment with their referred clients.
  • Date Format: MM slash DD slash YYYY
  • Client Information

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Primary Care Veterinarian Information

  • The primary veterinarian's cell phone number will only be used for Dr. Caroline Landry to contact them after hours with results if the veterinarian would like. This cell phone number will not be given to any one other than Dr. Caroline Landry.
  • Reason for Referral

  • Additional Medical History

  • Please send copies of any recent blood work and radiographs along with the patient to their appointment. Thank you for the referral!