Equine Podiatry Referral Form

This service is for veterinarians only – clients seeking self-referral or additional information should contact their regular veterinarian for more information.

Please provide a summary of the history of the case so that we can be prepared to provide the patient with the appropriate care. Please send or fax supporting information. Please send radiographs or other images with the client or by submitting directly to us through eFilm (see instructions here).

Referral Status(Required)

Expedited Referral (Please also call 919-513-6630 if this is an emergency)

Standard Referral

Remote Consultation Only

Veterinarian to Contact(Required)

Prefix First Last

Clinic Name(Required)

Clinic Phone Number(Required)

Phone

Clinic Email

Owner Contact Information

Name of the owner(Required)

First Last

Owner Phone(Required)

Owner Email(Required)

Owner Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Information

Horse's Name(Required)

Horse's Age

Breed

What is your main concern regarding your horse?

How often does it get its hooves done?

In relation to any x-rays, how recently were the hooves done?

In relation to any photos, how recently were the hooves done?

What shoeing or trimming strategies have been tried?

Is the horse currently shod?

Yes

Has the horse been having lameness issues or other problems? If so, how long have those issues been going on?

What is the name of your regular veterinarian and farrier?

What is the horse's normal job? What are the expectations or goals for the horse?

Does the patient currently have a confirmed or suspected infectious disease or known/suspected multidrug-resistant infection (e.g., MRSA, MRSP, CRE, ESBL-producing organisms)?(Required)

Yes

Does this patient have a current or pending culture?

Does this patient have a current or pending culture?(Required)

Yes