The HIP
24-HR ER: 262-542-3241
Our Services
Acupuncture
Anesthesia and Pain Management
Blood Bank
Cardiology
Dentistry
Dermatology
Diagnostic Imaging
Outpatient Ultrasound
Emergency/Critical Care
Internal Medicine
Neurology
Oncology
Ophthalmology
Surgery
For Your Pet
Client Registration Form
When Your Pet is a Patient
Pet Insurance
Payment Options
End of Life Arrangements
Grief Resources
Clinical Studies
For Veterinary Teams
COVID-19 Hospital Updates
Veterinary Team Resources
Imaging Forms and Portal
Continuing Education
VetBloom CE
Clinical Studies
About Us
Our Hospital
Our Team
Why Ethos
Contact Us
Blogs & Videos
Our Blogs
PAWEDcasts
We’re Hiring!
Apply Today
Benefits and Perks
Ethos Job Fairs
Vet Student Externships
Our Services
Acupuncture
Anesthesia and Pain Management
Blood Bank
Cardiology
Dentistry
Dermatology
Diagnostic Imaging
Outpatient Ultrasound
Emergency/Critical Care
Internal Medicine
Neurology
Oncology
Ophthalmology
Surgery
For Your Pet
Client Registration Form
When Your Pet is a Patient
Pet Insurance
Payment Options
End of Life Arrangements
Grief Resources
Clinical Studies
For Veterinary Teams
COVID-19 Hospital Updates
Veterinary Team Resources
Imaging Forms and Portal
Continuing Education
VetBloom CE
Clinical Studies
About Us
Our Hospital
Our Team
Why Ethos
Contact Us
Blogs & Videos
Our Blogs
PAWEDcasts
We’re Hiring!
Apply Today
Benefits and Perks
Ethos Job Fairs
Vet Student Externships
The HIP
24-HR ER: 262-542-3241
Referral Form
Non-Emergency Referrals
If you are transferring an Emergency patient, please call our offices at 866-542-3241.
Client Information
First Name
*
Last Name
*
Phone
*
Patient Information
Patient Name
*
Sex of Patient
*
Spayed Female
Neutered Male
Intact Female
Intact Male
Patient's Date of Birth, or Age (in years)
*
Species
*
Canine
Feline
Other
Breed
Referring Veterinarian Information
Referring Veterinarian
*
Referring Clinic
*
Referring Clinic Phone
*
Referring Clinic Fax
Referring Clinic Email
*
You will receive a confirmation copy of this form for your medical records.
Clinical Information
Immediate Problem
Select a Service
Acupuncture
Anesthesia/Pain Management
Blood Bank
Cardiology
Dentistry
Dermatology
Diagnostic Imaging
Internal Medicine
Neurology
Oncology
Ophthalmology
Surgery
Referral Type
*
Patient Referral
Image Review
Patient Transfer
Were X-rays taken?
Yes
No
Is this urgent?
Yes
No
Should we call client to schedule?
Yes
No
Medical History
Current Medications
Medication
Strength/Dose
Frequency
Other Treatments/Prior Medications
Diagnostics
Records and Images
Drop files here or
If you prefer, you can also send images directly to us via DICOM-send from your computer, or upload via the image portal.
Other Comments
Phone
This field is for validation purposes and should be left unchanged.