Emergency Referral Form

To refer a patient to the emergency service at Arkansas Veterinary Emergency & Specialists, please submit the form below, or download and fax to 501-224-3785.

Download Form

Referring Clinic / Doctor

Clinic Name *

Doctor Name *

Email Address *

Phone Number for Consultation *

Consultation Details *

Pet Owner Information

First Name *

Last Name *

Phone *

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

Please keep patient for workup

From Our Clients

"You were all so kind, caring and friendly from the phone call to picking him up after Briggs surgery was a great experience. I would highly recommend y’all to anyone needing your services. Thank you for being so good with Briggs and taking such good care of him! Thanks for making me feel better the whole time I was there and when when I came to pick him up!"
Tiffany E.