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About
About
Education
Careers
News
Support the Hospital
Animal Owners
Animal Owners
Emergency Services and Critical Care
Blood Bank
Feline Health Center
Referrals and Appointments
Prepare for Your Visit
Family Community Services
Billing and Payments
Pay Your Bill
Request Medical Records
Veterinarians
Veterinarians
Refer a Patient
Request a Consultation
Diagnostic Services
Continuing Education
MRI Scan
Services
Services
Small Animals
Exotics
Equine
Farm Animals
Tips and Resources
Tips and Resources
Animal Care Resources
Veterinarian Resources
Nutrition Resources
Clinical Trials
Animal Safety Tips
Pet Loss Support
Pharmacy
Contact Us
Contact Us
Hospital Directory
Directions
Give Now
NC State Omega Transitional Care Referral Form
Are you the owner or the veterinary clinic?
(Required)
Pet Owner
Clinic
Veterinarian Contact Information
Referral Status
(Required)
Expedited Referral
Standard Referral
Veterinarian to Contact
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Last
Clinic
(Required)
Clinic Phone Number
(Required)
Clinic Email
(Required)
Clinic Fax Number
Owner Contact Information
Client Contact
(Required)
I have asked client to call VH
Please call client for appointment.
Name of the owner
(Required)
First
Last
Owner Phone
(Required)
Owner Email
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Information about the patient
Has this patient ever been seen by any service at NC State Veterinary Hospital?
Yes
No
Not Sure
Patient/Pet Name
(Required)
Species
(Required)
Select One
Dog
Cat
Gender
(Required)
Select One
Male
Male/Castrated
Female
Female/Spayed
Date of Birth or Age
(Required)
Breed
(Required)
Weight (lbs/kgs)
(Required)
Patient History
Reason for referral/clinical history (include duration of illness, clinical signs, pertinent physical exam findings, lab work abnormalities, imaging findings, medications/interventions trialed.)
Diagnostic data accompanying referral (please email to cvm-omegaservice@ncsu.edu)
Laboratory
Radiographs (see instructions on main page)
Other Imaging
Vaccination History
Has the patient been rabies vaccinated in the last 3 years?
Yes
No
Date rabies vaccine administered
(Required)
MM slash DD slash YYYY
Medical reason precluding rabies vaccination (if any):
(Required)
Other Vaccines and Date Administered:
Upload File(s) of Patient's Medical Records
Drop files here or
Select files
Max. file size: 195 MB.
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