Behavior Service Referral

Client Name
Client Phone Client Phone - ### - ### ####
Secondary Phone Number Secondary Phone Number - ### - ### ####
Client Email
Species of pet/animal
Patient Name
Reason for Referral
Level of Urgency

IF URGENT: Please continue to fill out this form, but please also call us ASAP to discuss this case: 405-744-7000.
Appointment Schedule Preference
If appointment scheduled, when?

Please include date and time if known.
Referred By

Referring Veterinarian Information
Doctor's Name
Hospital or Practice
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email

A confirmation email will be sent to you after submitting.
Fax
How do you wish to be notified of results?

How do you wish to be notified of results? Phone Email Fax
Case History

Including duration of illness, clinical signs observed, lab and radiographic results (include radiographs), medical/surgical treatment given, vaccinations (date & vaccines given), diet, etc.
Upload a File

Attach Files

Attach any supporting documents, X-Rays, etc.
If not attached above, how will pertinent medical records be sent to OSU?

If not attached above, how will pertinent medical records be sent to OSU? Email to vet-behavior@okstate.edu (Preferred) Client will bring
Suggestions or Comments by referring veterinarian