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.

Referring Veterinarian




 


Client Information



 



Patient Information









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