Referral Form

Thank you for considering VIP Neurology or Virtual Neurology. Neurologic consultations begin with a referral from your veterinarian. Referring veterinarians may use the form below to request VIP Neurology or Virtual Neurology services. If you are a pet parent, please have your veterinarian submit the referral on your behalf.

DVM name

DVM license number & state

Clinic name

Clinic phone number

Preferred phone number (if different from clinic number)

Clinic email

Preferred email (if different from clinic email)

Pet owner's full name

Pet owner's email address

Pet owner's phone number

Patient signalment (include name, weight, age, gender, species, & breed)

Patient history

Neurologic exam findings

Diagnostics performed and pertinent results

Current / Recent treatments and response

Differential diagnoses and proposed plan

Is the pet owner ready to pursue MRI and spinal tap?

Yes

Undecided

*This pet has already undergone an MRI

*If an MRI has already been performed, please include the MRI images in addition to the radiologist report. The MRI images can be provided as a link or as dicom images.

Goals for consultation

Medical records and patient videos:

What Happens Next

Dr. Jennifer Rich will personally review your submission to determine the most appropriate care pathway for your patient.
Once the review is complete, scheduling and payment instructions will be sent by email to the appropriate recipient—either the pet owner (VIP Neurology) or the referring veterinarian (Virtual Neurology).

Dr. Jennifer Rich

Veterinary Neurology

Referral Form