Referral Form

Thank you for your trust in Zodiac Pet & Exotic Hospital. We are committed to providing the highest standard of care for your clients and patients. Please complete the form below and attach all relevant medical records to ensure a timely and appropriate follow-up.

Referring Clinic's Name

Referring Veterinarian's Name

Contact Number

Email Address

Emergency

Referral for

(For CT Scan only) How many part(s) of CT Scan is(are) required??

(For CT Scan only) Which part(s) of the following is(are) required?

Head Thorax Abdomen Others

(For CT Scan only) Contrast required?

Yes No

(For CT Scan only) Sedation required?

Yes No

(For CT Scan only) Expected Turn around time for CT reporting

Standard Enhance (48 Business Hour) Priority (Up to 24 Hour)

(For CT Scan only) Clinical History and Physical Examination Findings Clinical Questions to be answered?

Referral for other, please specify

Owner's Name

Contact Number

Pet's Name

Species

Other species, please specify

Breed

Sex

Weight in kg

Date of Birth / Age

Reason for referral

Diagnostics Performed

Current & Previous Treatment/Medication(s)

Other Comments

Please attach relevant medical records below including medical history, laboratory results and imaging results.

Regarding Medical Records: By submitting the relevant medical records to Zodiac Pet & Exotic Hospital, you agree that the submitted records can be provided to the pet owner should they request a copy.
For Urgent Cases: * If your patient requires an immediate transfer, please call us at 2527 1718 after submitting this form to ensure a smooth handover.
Owner Consent & Privacy Policy: By submitting this form, I acknowledge that I have informed the pet owner that I am referring the case to Zodiac Pet & Exotic Hospital and have obtained their consent to share their personal data with the hospital for this purpose.

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