Referral Form

Advanced, Extensive Referral Care

Are you a veterinarian who would like to refer a patient to Carolina Veterinary Specialists in Rock Hill? Please complete and submit the form below or download and fax it to (803) 327-1698.

Download Referral Form

Referring Veterinarian

Hospital Name *

Veterinarian Name *

Phone *

Email *

Specialty Service Requested

Choose Applicable Services *

Surgery

Emergency Medicine

Outpatient Ultrasound

Patient Information

Owner First Name *

Owner Last Name *

Owner Phone *

Owner Email

Patient Name *

Breed *

Age *

Sex *

Brief Medical History *

Please upload any documents you would like to provide in PDF or JPEG format.

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Medical Records (Check all that apply) *

Medical Records Provided

Medical Records Sent Separately

Radiographs Emailed

Client to Bring Radiographs to Appointment

None

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