Referral Form

Download and Print

  • Personal Information

  • In case of an EMERGENCY whom (other than the above) should we call?

  • Pet Information

  • Date Format: MM slash DD slash YYYY
  • Referring Veterinarian Information

  • Referral Policy: If you have been referred here by your primary care veterinarian for emergency care and/or specialty care, you will be returning to that veterinarian for routine care. Unless otherwise instructed, I fully authorize Animal Hospital at Baldwin Park to release any or all of my pet’s records to my referring veterinarian. Please be aware that we will only treat your pet’s present problem. Under no circumstances will we accept your pet for unrelated problems (i.e.; vaccines, boarding, bathing, routine care, etc.) unless once again referred by your veterinarian. Your cooperation is appreciated.
    I hereby authorize the veterinarian to examine, prescribe or treat my pet(s). A written estimate of fees will be provided upon my request. I assume responsibility for all charges incurred in the care of my pet(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment and/or hospitalization.

    All FEES ARE DUE AND PAYABLE AT TIME SERVICES ARE RENDERED