Veterinarian Referral Form Referring veterinarians please use this form to provide information regarding our patient. Veterinarian Referral Form To be filled out by your veterinarian Owner InformationName* First Last Phone Number*Cell PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient InformationName* Weight* Species* Breed* Sex* Age* History*Diagnostic Tests Performed*Previous Treatment (Include Dosages)*Current Treatments (Include Dosages)*Date of Last Rabies Vaccine:* MM slash DD slash YYYY Expiration Date:* MM slash DD slash YYYY Heartworm Test Date: MM slash DD slash YYYY Results Referring VeterinarianName* First Last Name of Hospital* Phone (xxx)xxx-xxxx*Fax (xxx)xxx-xxxxEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Note: In addition to submitting this form, please email staff@itchydog.net or fax (978) 399-0200 all dermatology related patient records and any diagnostics performed including (bloodwork, biopsy, cytology, prior allergy testing). Thank you! ONLINE FORMS Dermatology History Policy Agreement Veterinarian Referral View PDF version of this form