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Referral Form

The following form may be completed by veterinarians only who are referring clients to the Auburn University Small Animal Hospital.  

DO NOT USE THIS FORM IF THIS IS AN EMERGENCY!

Please complete all fields below and press the SEND button. Wait for a confirmation page after submitting your request. If you do not receive the confirmation page, your form was not properly processed and should be resubmitted. 

A valid e-mail address is required to use this form. Please enter your e-mail address carefully.  

Required field are indicated by *.

The faculty of the Small Animal Hospital recognize that the basis for proper medical referral care and communication begins with the information you provide.

Appointments are necessary, but every attempt will be made to make your client welcome. It will help your client to know that the Small Animal Hospital does not routinely bill. Payment by cash, check, VISA, or MASTERCARD is accepted. Care credit is available if requested by the owner.  A deposit of the median point between the high and low estimate is due on admission and the balance on discharge.

From (your email) *
Subject Small Animal Patient Referral
How do you wish to handle this referral? *
(Your office will be contacted if client can not be.)
Service Referring To *
Has this patient been to Auburn before? *



Client Name *
Client Address *
Client Address 2
Client City *
Client State
Client Zip Code *
Client Home Phone *
Client Business Phone
Referring Veterinarian *
Hospital Name
Hospital Email Address
Hospital Address
Hospital Address 2
Hospital City
Hospital State
Hospital Zip Code
Hospital Phone *
Hospital FAX
Patient Name *
Species *
If other please specify
Patient Breed
Patient's Age *
years - months (3-10)
Patient's Sex *
Patient's Weight *
(In pounds)
Please check any vaccine that has been given to the patient. If a vaccine has not been given, please leave the field blank.






Please give the dates that the vaccines above were last administered. Please list each vaccine and it's date separately.

Current Heart Worm Status
Is the patient on heartworm preventative?
FELV Status *
FIV Status *
Date of last examination at your office *
Reason for Referral *

History *

Treatment *

I plan to forward copies of the following patient information at the time of referral











(Please check all that apply)
I am a licensed veterinarian practicing within the United States. All of the information entered in this form is accurate and trustworthy to the best of my knowledge. If this statement is true, please type your initials int he following box. *
(This will serve as your signature for the purpose of this form)

Auburn University | College of Veterinary Medicine | Auburn, Alabama 36849 | (334) 844-4546
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