Page 1 of 1

Referring Veterinarian Form

Keith Blass, DVM, DACVIM (Cardiology)
Jacqueline Gest, DVM, DACVIM (Internal Medicine)
Caroline Hohlman, DVM, DACVIM (Oncology)
Ariel Kravitz, DVM, DACVS- SA, CVA (Surgery)
Carol Margolis, DVM, DACT (Theriogenology)
Victoria Kearns, LVT, CCRP, NCM, OACM (Rehab)
Riley Palmese, LVT, CCAT (Rehab)
Megan Petroff, DVM (Practice Limited to Behavior)
Hi!

It is a great privilege for Gold Coast Center for Veterinary Care to be able to provide you and your pet with our specialty services.
It is our goal to be a vital extension of your veterinarian's practice and to assist in the necessary specialty care that your pet requires.
As a specialty center, we must comply with certain obligations that are inherent with the services we are providing.
If you have a referring veterinarian, we will not under any circumstances, nor will any of our affiliates (West Hills Animal Hospital, Locust Valley Veterinary Clinic, Oyster Bay Animal Hospital, West Hills Animal Hospital North, or Court Square Animal Hospital), provide any elective services or routine care such as vaccinations, or elective dental services, etc. for your pet or dispense any refills for chronic or preventative medications.
The drugs we will dispense will be strictly to treat the problem your pet presented to us for. We will submit all medical records, laboratory tests, and any imaging that your pet has undergone while in our care to your referring veterinarian. We will also keep your referring veterinarian abreast of any changes in the status of your pets' condition as it occurs.
No exceptions to this policy can be made under any circumstances.
If your referring veterinarian has changed please inform the front desk.
If you do not have or no longer have a referring veterinarian please write none next to the referring veterinarian's name.

Referring Veterinarian / Veterinary:

Patient Name:

Signature:

Signature

Date: