Referral Form for Veterinarians

Thank you for referring your patient to Midwestern University’s Companion Animal Clinic.

Thank you for referring your patient to Midwestern University’s Companion Animal Clinic. If you are a veterinarian referring a patient to one of our specialty services such as surgery, internal medicine, or neurology, please complete the referral form and submit all medical records, including imaging, to our clinic email at ahi@midwestern.edu

Clinic & Referral Details

Which service(s) are you referring?
Preferred Contact Method

Client Information

Patient Information

Sex

Patient Medical Background

Previous Diagnostics
One file only.
100 MB limit.
Allowed types: gif jpg jpeg png bmp eps tif pict psd txt rtf html odf pdf doc docx ppt pptx xls xlsx xml avi mov mp3 mp4 ogg wav bz2 dmg gz jar rar sit svg tar zip.

Medication History

 

Medical records can be emailed to ahi@midwestern.edu