Referral Request Referral Form Request type * Advice/Consultation Appointment *** Please note as you are requesting an appointment, our clinicians will not be reaching out to you. Please have your client call us to make an appointment at 608-263-7600 for small animals and 608-263-6300 for large animals. Referring Patient to (Visit time frames for most services are currently booking 1-6 months out. Dermatology availability is currently limited. For urgent/emergent concerns, please call 608-263-7600)Select a service: * CardiologyDentistry & Oral SurgeryEquine Standing CTGeneral SurgeryLarge Animal SurgeryMedical OncologyNeurologyOphthalmologyOrthopedic SurgeryPhysical RehabilitationRadiation OncologySmall Animal Internal MedicineSpecial Species Referring DVM Expectation for this case * Owner Name * Owner Address * Owner Address Owner Address Owner Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Owner Phone Number * Owner Email * Referring DVM Name * Referring Clinic Name * Referring Clinic Address * Referring Clinic Address Referring Clinic Address Referring Clinic Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Referring Clinic Phone Number * Referring Clinic Email * Animal Name * Species * Canine Feline Exotic Other (please specify)Other (please specify) Exotic species type (e.g. Fish, rabbit, bird) * Breed * Animal date of birth * Sex * Male Male Castrated Female Female Spayed OtherOther Color * Primary Reason for Referral (include as much information as possible) * Medical History Related to Referral * Location * HeadNeckFootFetlockMetacarpusCarpusMetatarsusTarsus Has prior imaging been performed? * YesNo * Referral for physical rehabilitation therapy evaluation and treatment as indicated by Courtney Arnoldy DPT, CCRP *** If images have not yet been sent to UWVC, please send them to radimages@vetmed.wisc.edu Is further work-up through large animal surgery or medicine desired? * YesNo Please indicate how you have sent patient records to UWVC - If you have diagnostic images and photos, please send those as well. * Email to referral@vetmed.wisc.edu Fax # 608-265-8276 Handling precautions or any other additional details that we should know? Specific questions / Concerns be addressed Please advise your client to call and schedule an appointment if that is what you would like. Our phone numbers are below: Small Animal Hospital: 608-263-7600 Large Animal hospital: 608-263-6300 Physical Rehab: 608-890-0422 reCAPTCHA Submit If you are human, leave this field blank.