Referral form


A form like this can be used when referring to a holistic veterinarian, eg for support during chemotherapy, pre treatment before surgery or post operatively

or when a AHV member is referring away from his or her practice eg for exploratory surgery or diagnosis.

Whilst it is often desirable to make personal contact with referring Veterinarians it is not always possible and the use of forms such as these can provide relevant details and feedback to ensure that the animals receive the best possible care.


Form: Please feel free to print out, and to cut and paste and alter as needed to enlarge segments:



Reason for referral:

Referred to:

Owner Details




Species: Breed:

Age: Sex: Name:

Pet Details:


Treatment to Date:


Laboratory Reports Radiographs Other

Referring Veterinarian: Clinic: including e mail, phone and fax

(Please complete or attach separate history and fax prior to appointment)