Skip to content

Now Offering Wellness Plans! Click Here to Learn More!

248-644-7171 Call

Make an Appointment

Home
Our Hospital
Urgent Care
Services
Careers
Shop Online
Referring Veterinarians
- Referral Form
Contact Us

Home
Our Hospital
Urgent Care
Services
Careers
Shop Online
Referring Veterinarians
- Referral Form
Contact Us

248-644-7171 Make an Appointment

Home » Forms » Referral Form

Referral Form

Referring Veterinarian(s)

Clinic Name

Phone(Required)

FAX

Email(Required)

Name of Client

First Name

Last Name

Address of Client(Required)

Street Address

Street Address Line 2

City

State / Province / Region

ZIP / Postal Code

Canadian address?

Canadian address?

Address

Street Address

Street Address Line 2

City

State / Province / Region

ZIP / Postal Code

Phone(Required)

Business Phone

Name of Patient(Required)

Species(Required)

Breed(Required)

Color

Sex(Required)

Birth Date(Required)

Vaccination history

Tentative Diagnosis:(Required)

History/Physical findings:(Required)

Laboratory Data (attach additional sheets if possible):

Treatments (include medication and dosages):

Radiographs

Attached below

Emailed separately

None taken

Medical records and laboratory date

Attached below

Emailed separately

File Upload

Drop files here or

Max. file size: 50 MB.

Special Requests/ Comments(Required)

Gasow service requested/recommended(Required)

CT (helical)

Abdominal ultrasound

Echocardiogram

GI endoscopy

Laparoscopic spay +/- gastropexy

Rhinoscopy

Otoscopy

Note for scheduling appointments – Our team will call your client to schedule their appointment with us. Following the visit, we will send the records and results to you.

For advanced diagnostics (CT, endoscopy, rhinoscopy, ultrasound, echocardiogram), please select an option below(Required)

We call client with results or

We send all results to you for review with the client

Make an Appointment

Pharmacy

Find Us

Make an Appointment 248-644-7171

36877 Woodward Ave
Birmingham, MI 48009

Pharmacy

Business Hours

Monday

8:00am - 9:00pm*

Tuesday

8:00am - 9:00pm*

Wednesday

8:00am - 9:00pm*

Thursday

8:00am - 9:00pm*

Friday

8:00am - 9:00pm*

Saturday

9:00am - 4:00pm*

Sunday

9:00am - 7:00pm*

*Monday - Friday: Urgent Care Starts at 5:30pm. Saturday - Sunday: Urgent Care Only. Additional Fees May Apply.

©Copyright 2026 - Birmingham Vet - Gasow Veterinary Hospital. Sitemap | Privacy Policy