Lehigh Valley Veterinary Dermatology

4580 Crackersport Rd
Allentown, PA 18104

(610)391-1200

lehighvetderm.com

Referral Form

Referring Veterinarian Name (required)

Hospital Name (required)

Referring Vet E-Mail (required) :
Owner Name (required)
First Name (required)
Last Name (required)
Owner Phone (required)
Phone TypePhone Number (required)
Pet Name (required)

Species :
Breed

Sex
MC
FS
F
M


Date of Birth

Has the owner already scheduled an appointment?
yes
no
unsure


Appointment Date

Records can be faxed to 610-391-1212 or emailed to referral@lehighvetderm.com
Case History

Diagnostic Tests/Results

Treatments and Response (please indicate current treatment)


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