Specialist Referral - Surgery

Name: Arkansas Veterinary Emergency & Specialists
Address: 11619 Pleasant Ridge Rd, Little Rock, AR, 72212, US
Telephone: (501) 224-3784

To refer a patient to a Surgery Specialist, please submit the form below.

PLEASE NOTE: To book an appointment, please call (501) 224-3784 .

Dr. Name *

Hospital Name *

Email Address *

Phone *

Fax

Other Information Provided

Medical Records

Radiographs

Images

Synopsis Letter

Other

Client (Owner) First Name *

Client (Owner) Last Name *

Phone *

Pet's Name *

Species *

Breed

Gender *

Male

Female

Neutered / Spayed? *

Yes

Date of Birth *

Color *

Vaccinations (Date of Last): Distemper *

Vaccinations (Date of Last): FeLV *

Vaccinations (Date of Last): Rabies *

Vaccinations (Date of Last): HWT *

Significant Past Medical History / Problems

Current Problem (please indicate/describe chief complaint / onset / progression / treatments)

Tentative Diagnosis Given to Client *

Medications (please list all current medications and dosages)

A Referral Report will be faxed to you shortly after your client's visit. If you have another preference, please let us know. Email:

Additional Comments

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From Our Clients

"We were very impressed with everyone on staff. We ended up having to euthanize our sweet dog because of an injury resulting in paralysis. The staff was very sensitive to our situation and offered their condolences several times. The staff explained every option to us including costs. We found them all to be very professional and caring. I would definitely recommend this clinic to anyone needing emergent care for their pet."
Shelley M.