Ham Lake Veterinary Hospital

Veterinary Referral Form

Ham Lake proudly partners with veterinary practices and veterinarians in the Ham Lake/East Bethel communities to provide acupuncture services as an extension of services. Interested in referring a patient to us? We’d love to help.

Thank you for choosing Ham Lake Veterinary Hospital.

Client Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Name *

Date of Birth *

Sex *

Male
Female

Weight *

Breed *

Color *

Neutered or spayed *

Yes
No

REFERRING VETERINARIAN PLEASE COMPLETE THE FOLLOWING

Referring Veterinarian *

Clinic *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Reason for Referral/Working Diagnosis

History / Medical Conditions

Treatments / Medications

Additional Information

Upload Results / Related Records

Click or drag files to this area to upload. You can upload up to 5 files.

Signature

Ham Lake Veterinary Hospital

Veterinary Referral Form

Thank you for choosing Ham Lake Veterinary Hospital.

REFERRING VETERINARIAN PLEASE COMPLETE THE FOLLOWING

Ready to visit?

Your Ham Lake Veterinary Hospital

Download Our App!

have a question?

Contact Our Hospital

Address

Hours

Contact