Client Referral Form

Save time by completing your required form online before your visit! Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Book Appointment

Date *

Doctor Name *

First

Last

Practice Name *

Laboratory Name

Doctor E-mail *

Doctor Phone *

Doctor Fax

How would you like to be contacted?

Phone
Email
Fax

Client Name *

First

Last

Patient Name *

First

Last

Patient Species *

Dog
Cat
Other

Please upload lab reports, x-rays, and other diagnostics.

Click or drag a file to this area to upload.

Additional Upload (if necessary)

Click or drag a file to this area to upload.

Additional Upload (if necessary)

Click or drag a file to this area to upload.

Additional Upload (if necessary)

Click or drag a file to this area to upload.

Patient History

Diagnostic Information

Treatments / Medications

As the referring veterinarian, my expectations for this case are as follows: (Please check one.)

Referral for procedure(s)
Hospitalization and definitive care
Overall management of care for the diagnosis
Overnight care and return in the morning

Is there any more information we should know?

Comment

Ready To Visit?

We proudly serve the pets of Colchester, Montville, Bozrah, Lyme, East Lyme, East Haddam, Norwich, and surrounding areas. You can schedule an appointment by calling us directly or clicking the button below.

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Location

12 Centre Street
Salem, CT 06420

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Get in Touch

Phone: 860-859-1649
Fax: 860-859-3781
General Practice: info@salemvalleyvet.com
Dental: dentistry@salemvalleyvet.com

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Hours

Monday: 8 AM – 7 PM
Tue – Fri: 8 AM – 5 PM
Saturday-Sunday: Closed
(closed each day 12:30pm-1:30pm)