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Surgery Referral Form (Dr. van Ee)

2288 Sheridan Drive • Buffalo, New York 14223
Telephone (716) 833-5345 • Fax (716) 833-8525

Please note: This form should be completed and submitted by the referring veterinarian, not the client.

Referring Doctor*

Referring Hospital*

Hospital Phone #*

Client Information

Owner's Name*

Phone Number*

Street Address

City, State

Zip Code

Patient Information

Patient's Name





Date of Birth/Approximate Age

Vaccination Dates (Rabies MUST be current):

Please attach ALL recent blood/labwork below:

Referral Information

Date Referred:

Duration of Problem:

Were radiographs done?

If yes, they were:
EmailedDisc/Films Sent With OwnerOther

Reason for Referral:

History (include any treatments, dates, etc.):

Special Considerations:

Current medications & dosages:

Referral letters should be emailed/faxed to: