Boston Veterinary Specialists

Referral Form

Thank you for choosing Boston Veterinary Specialists! Complete your referral form online from any device at any time.

Online Forms

Referral Form

(This form online is not required. You can send us an email instead.)

For your convenience, you may complete the following referral form and submit it through our website. Dr. Briere or one of our team members will be in touch with you as soon as possible. You may also download a PDF to complete and fax, mail, or hand deliver to our office.

Please be sure to attach or fax all pertinent records, reports, and diagnostic images with the pet owner to the appointment. Fax: (781) 326-9782. Email: info@bostonvetspecialists.com

Have a difficult surgery case? Our board-certified surgeons are here to help! Give us a call at 781-326-2140 for a free consultation!

Owner Information

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone (Home)

Phone (Work)

Phone (Other)

Patient Information

Registered Name/ID *

Species *

Age *

Breed *

Weight *

Chief concern/Provisional Diagnosis/History: *

Vaccine History

Dates last given:

Distemper *

Rabies *

Kennel cough *

felv: *

Diagnostic Test Results (If possible, please attach results):

Last done:

Chem. Panel *

CBC *

U/A *

T4 *

Additional Upload (if necessary)

Click or drag a file to this area to upload.

Are radiographs enclosed?

Current therapy & medication (include dosages):

Additional comments/requests:

Referring Veterinarian Information:

Name *

First

Last

Clinic/ Hospital *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Fax

Additional Upload (if necessary)

Click or drag a file to this area to upload.

Message

Boston Veterinary Specialists

Referral Form

Online Forms

Referral Form

Owner Information

Patient Information

Vaccine History

Diagnostic Test Results (If possible, please attach results):

Referring Veterinarian Information:

Your Surgical Specialists in Dedham, MA

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