The HIP
24-HR ER: 262-553-9223
Our Services
Acupuncture
Anesthesia and Pain Management
Cardiology
Dermatology
Diagnostic Imaging
Emergency/Critical Care
Oncology
Ophthalmology
Social Work
Surgery
For Your Pet
Emergencies + Appointments
Client Registration Form
Get in Line
When Your Pet is a Patient
Blood Bank
Online Store
Pet Insurance
Payment Options
End of Life Arrangements
Grief Resources
For Veterinary Teams
Veterinary Team Resources
At a Glance
Imaging Forms and Portal
Clinical Studies
VetBloom CE
Ethos Materials for Clinics
Continuing Education
About Us
Our Hospital
Our Team
Why Ethos
Ethos Discovery
Contact Us
Blogs & Videos
Our Blogs
PAWEDcasts
We’re Hiring!
Apply Today
Ethos Job Fairs
Benefits and Perks
Veterinary Training Programs
Our Services
Acupuncture
Anesthesia and Pain Management
Cardiology
Dermatology
Diagnostic Imaging
Emergency/Critical Care
Oncology
Ophthalmology
Social Work
Surgery
For Your Pet
Emergencies + Appointments
Client Registration Form
Get in Line
When Your Pet is a Patient
Blood Bank
Online Store
Pet Insurance
Payment Options
End of Life Arrangements
Grief Resources
For Veterinary Teams
Veterinary Team Resources
At a Glance
Imaging Forms and Portal
Clinical Studies
VetBloom CE
Ethos Materials for Clinics
Continuing Education
About Us
Our Hospital
Our Team
Why Ethos
Ethos Discovery
Contact Us
Blogs & Videos
Our Blogs
PAWEDcasts
We’re Hiring!
Apply Today
Ethos Job Fairs
Benefits and Perks
Veterinary Training Programs
The HIP
24-HR ER: 262-553-9223
Referral Form
Non-Emergency Referrals
If you are transferring an Emergency patient, please call our offices at 866-542-3241.
Client Information
First Name
*
Last Name
*
Phone
*
Patient Information
Patient Name
*
Sex of Patient
*
Spayed Female
Neutered Male
Intact Female
Intact Male
Patient's Date of Birth, or Age (in years)
*
Species
*
Canine
Feline
Other
Breed
Referring Veterinarian Information
Referring Veterinarian
*
Referring Clinic
*
Referring Clinic Phone
*
Referring Clinic Fax
Referring Clinic Email
*
You will receive a confirmation copy of this form for your medical records.
Clinical Information
Immediate Problem
Select a Service
Acupuncture
Anesthesia/Pain Management
Cardiology
Dermatology
Diagnostic Imaging
Ophthalmology
Surgery
Referral Type
*
Patient Referral
Image Review
Patient Transfer
Were X-rays taken?
Yes
No
Is this urgent?
Yes
No
Should we call client to schedule?
Yes
No
Medical History
Current Medications
Medication
Strength/Dose
Frequency
Other Treatments/Prior Medications
Diagnostics
Records and Images
Drop files here or
Select files
Max. file size: 20 MB, Max. files: 10.
If you prefer, you can also send images directly to us via DICOM-send from your computer, or upload via the image portal.
Other Comments
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