© 2016 Carolina Veterinary Specialists PV535_ReferralForm_0216 For directions, visit carolinavet.com PATIENT / PET NAME DATE Please follow these directions: Go directly to hospital listed below to be seen on emergency basis Call the number listed below and make appointment with: Matthews Cardiology Emergency Medicine Internal Medicine Medical Oncology Neurology Outpatient Ultrasound Radiation Oncology Surgery Charlotte Emergency Medicine Internal Medicine Neurology Ophthalmology Outpatient Ultrasound Surgery Huntersville Avian/Exotic Pets Behavior Emergency Medicine Internal Medicine Outpatient Ultrasound Surgery Greensboro Behavior Emergency Medicine Internal Medicine Medical Oncology Ophthalmology Outpatient Ultrasound Radiology Surgery Winston-Salem Emergency Medicine Internal Medicine Neurology Ophthalmology Outpatient Ultrasound Rehabilitation Surgery Patient Information: BREED AGE SEX CLIENT NAME CONTACT INFO Medical records provided Medical records sent separately Radiographs emailed Client to bring radiographs to appointment Referred by: HOSPITAL NAME VETERINARIAN PHONE NUMBER EMAIL ADDRESS Brief Medical History: Appointment: DATE / TIME DOCTOR Referral Form Matthews 4099 Campus Ridge Road Matthews, NC 28104 PHONE 704.815.3939 FAX 704.815.3940 Charlotte 2225 Township Road Charlotte, NC 28273 PHONE 704.504.9608 FAX 704.504.9606 Huntersville 12117 Statesville Road Huntersville, NC 28078 PHONE 704.949.1100 FAX 704.949.1101 Greensboro 501 Nicholas Road Greensboro, NC 27409 PHONE 336.632.0605 FAX 336.632.0703 Winston-Salem 1600 Hanes Mall Boulevard Winston Salem, NC 27103 PHONE 336.896.0902 FAX 336.896.1969