Emergency Referral Form

To refer a patient to the emergency service at Memphis Veterinary Specialists & Emergency, please submit the form below, or download and fax to (901) 624-9014.

Download Form

Referring Clinic / Doctor

Clinic Name *

Doctor Name *

Email Address *

Phone Number for Consultation *

Consultation Details *

Pet Owner Information

First Name *

Last Name *

Phone *

Email Address

Address *

City *

State *

Zip Code *

Patient Information

Pet Name *

Age / Date of Birth *

Species *

Breed *

Sex *

Weight (lb/kg) *

Emergency Information

Presenting Complaint *

Diagnosis / Differentials *

Current Medications, Labratory Findings, Recent Surgery, Other. Please include the time medicine was last given or when treatments were complete. Send radiographs and copy of blood work with owner. *

Instructions for Emergency Doctor. Please include medication doses, route of administration, fluid type and rate. *

Upload any relevant documents

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Next Steps (Please check all that apply) *

Bill us for client charges

Patient is to return to my hospital for continued care

Please keep patient for workup

From Happy Pet Owners

“Forever thankful to kind, sweet, gentle, wonderful Dr. Tina Brown. Our 3 year old girl has been sick for months, but after one month she is back to feeling her happy, playful self again. It feels wonderful to have such an excellent support system in place when I need help.”
Dale C.