[email protected]

Home
About
Services
Resources
- Surgical Consent Forms
Referral Request

Select Page

Roam Veterinary Surgery



Referral Request Form (Soft Tissue)



Referral Request Form (Soft Tissue)

Please fill out Referral Request Form (Soft Tissue) as completely and accurately as possible.

Referring Veterinarian *

Referring Hospital: *

Referring Email Address: *

Pet’s name: *

Client’s name: *

Pet’s DOB: *

Breed *

Weight(kg): *

Sex: *

Male
Female

Altered *

Yes
No

Diagnosis: *

Location (if applicable): *

Side (if applicable):

Right
Left

Cytology/histopathology results?

Radiographs performed? *

YES
NO

Radiology review performed? *

YES
NO

Thoracic radiographs performed? (required for all trauma causes) *

YES
NO

Bloodwork performed? (required within 1-2 weeks for all surgeries) *

YES
NO

**Please email all cytology/histopath, bloodwork, radiographs, and radiology reports to [email protected].

Please list all medications:

Any co-morbidities? (ex: endocrinopathies, renal/hepatic disease, cardiac disease)

Any other relevant information to patient/case?

Comment

Referral Request

If you are a referring veterinarian or veterinary team member please click here to submit a scheduling request.

Referral Form

© 2025 Roam Veterinary Surgery | Powered by PetDesk