Kahua Veterinary Rehabilitation & Acupuncture

Veterinary Referral Form

If you are a referring veterinary practice, please fill out and submit the form below. If you have any digital records pertaining to your referral, they can be attached and sent here.

Referring Veterinary Clinic/Hospital

Referring Veterinarian

First Name

Last Name

Clinic Email Address

Clinic Phone Number

(###)

###

####

Owner Name

First Name

Last Name

Owner Email

Owner Phone Number

(###)

###

####

Owner Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Name

Patient Age

Patient Sex

Male

Female

Neutered/Spayed/Gelded

Patient Weight (approximate)

Patient Breed

Reason for Referral

Records

Please submit your patient’s most recent medical records including any recent bloodwork or x-rays. Please check which forms of records will be sent.

Medical records (for within the last year)

X-rays (include radiologist report if given)

Bloodwork (within the last year)

CT Scan (include radiologist report)

Please upload any patient records relevant to your referral

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Past Pertinent History:

Current Treatment(s) and Medication(s):

Additional Comments

For Referring Veterinarians

Veterinary Referral Form

Serving Oahu islandwide