Referring Veterinarians

Referral Form

Thank you for entrusting Veterinary Emergency Services of Lincoln with the emergency needs of your patients. We deeply appreciate our collaborative partnership and the confidence you have placed in us.

Your trust in us means a lot, and we are excited about the chance to serve you by providing top-tier care for your patients. We look forward to furthering this valuable collaboration.

If you are referring a patient to Veterinary Emergency Services of Lincoln, please fill out our digital form below. You can also download and complete the form and fax it to 402- 489-6826 or email it to uvetsstaff@gmail.com. Please make sure to call/send paperwork prior to your patient’s visit.

Download Form

Referring Veterinarian Information

Transferring Clinic/DVM Name(Required)

DVM Phone(Required)

Ok to Call DVM with Questions?(Required)

Patient Information

Patient's Name(Required)

Date of Birth/Approximate Age

Breed(Required)

Sex(Required)

Client Information

Owner Name(Required)

First Last

Address

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

Home Phone(Required)

Cell Phone

Email

Medical History

On routine medication (heartworm prevention, thyroid, etc.)(Required)

Medical History

Tentative Diagnosis

Recent Diagnostics

CBC

Chemistry

Urinalysis

Radiographs

Fecal

Other

**Please attach a copy and/or interpretation of all diagnostics done and medical records

If 'Other', please provide more details on diagnostic ran:

Please attach a copy and/or interpretation of all diagnostics done

Max. file size: 15 MB.

Any Diagnostics requested to be performed at VES?

Fluid Type

Fluid Rate (mLs/hr)

Medication

Please List all Medications that were given and that you would like to be given/repeated at VES.

Medications List

Drug Name

Amount (ml's)

Amount (mg's)

Route

Time Given (today)

Time Due at VES

To add additional medications, please click the '+' sign.

In the Morning:

I have explained to my client that Veterinary Emergency Services of Lincoln charged for services rendered.
All outpatients are required to pay in full at the time of services. All inpatients are required to pay 7 5% of the lowest amount of the estimate at the time of admission and the remaining balance at the time of discharge.
Please feel free to call with the veterinarian and licensed veterinary technicians with any additional information or concerns.

Referring DVM Signature

First Last

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Referring Veterinarians

Referral Form

Referring Veterinarian Information

Patient Information

Client Information

Medical History

Medication

Hours of Operation

Contact Info