Pet Allergy & Dermatology Specialists

4580 Crackersport Rd
Allentown, PA 18104

(610)391-1200

lehighvetderm.com

Referral Form

Or fill out the below form to submit online

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 Type	Phone Number (required)

Pet Name (required)

Species

dog
cat
other

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 info@lehighvetderm.com

Case History

Diagnostic Tests/Results

Treatments and Response (please indicate current treatment)

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