Referring Veterinarian Form - Synergy Integrative Veterinary Clinic

Please use this form to submit a patient referral request to Synergy Integrative Veterinary Clinic (SIVC).

This form is for veterinarians only – pet owners seeking to schedule an appointment should use the new client information form.

Please provide a summary of the history of the case so that we can be prepared to provide the patient with the appropriate care. Please complete each section of the form for complete submission of your client referral.

If this is an URGENT REFERRAL (i.e. needs to be seen within 24hrs), please call (252) 631-5033 immediately after submitting the information below.

Step 1 of 3 - Veterinarian Contact Information

Veterinarian Contact Information
Veterinarian to Contact*
Clinic/Hospital*
Clinic/Contact Phone Number*
Clinic Fax Number
Clinic/Contact Email Address*

Please use this form to submit a patient referral request to Synergy Integrative Veterinary Clinic (SIVC).

Step 1 of 3 - Veterinarian Contact Information

Veterinarian Contact Information

Pet Owner Contact Information

Patient Information