DVM Referral Form

If you prefer to fax us a referral, simply print and fax this form: Referral Form.
If you would like to refer a patient to AEC using our online submittal, please complete the form below...

You may optionally upload any diagnostic files, x-ray .jpg images or other patient documents as required. We will process your submittal at the hospital location you select, and send a confirmation email back to you indicating that we have received your information.

Note: If you would like to do a DICOM send directly from your digital radiography system to AEC, please contact us for assistance: DICOM Send.

* Refer To : NoviRochester

Referring Veterinarian

* Veterinarian Name :
* Clinic/Practice Name :
* Address :
* City :
* State : ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY   * Zip :
* Phone :
Fax :
E-Mail :

Client Information

* Owner Name :
* Address :
* City :
* State : ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY   * Zip :
* Home Phone :
Work Phone :
Cell Phone :
E-Mail :

Patient Information

* Pet Name :
Pet Age :
Or Birthdate :
Species :
Breed :
Sex :MaleFemaleSpayed/Neutered

* Chief Concern / Provisional Diagnosis :
History & Physical Findings :
Laboratory Data :

Radiographs :
Current Therapy and Medications :
Additional Notes / Comments :

You may attach lab data, radiographs, or additional files below.

First Attachment :
Second Attachment :
Third Attachment :

Submit Referral