Ophthalmology Consult and Referral Form

This service is for veterinarians only – clients seeking medical information should contact their regular veterinarian for assistance.

If you would like to make a referral to the Small Animal or Equine Ophthalmology service and you do NOT need to speak to an Ophthalmology clinician, you can use this form to submit the client and patient information.

For Farm Animals or Exotics, please submit a referral directly through those respective services.

Please attach to this online form, send via email (ncstateophthalmology@ncsu.edu), or fax (919.513.6711) supporting information, such as eye photos, records, diagnostic test results, or radiographs/ultrasound reports.

Click here for tips on how to take eye photos with your smart phone.

Veterinarian Contact Information

Emergency Referral

If this is an Emergency Referral (weekdays 8AM – 4:30PM), please call the NCSU Ophthalmology service directly at 919.513.6659 (small animal) or 919.513.6630 (equine) to speak with an Ophthalmology clinician AND/OR fill this form. Note, online referral forms are checked every 3 hours and thus responses will be delayed.
If this is an Emergency Referral (after hours, on weekends, or holidays) please call the NCSU Emergency service directly at 919.513.6911 (small animal and equine).

Standard Referral

The Ophthalmology service will contact the client to schedule an appointment within 2 business days.

Phone or Email consult only

An Ophthalmology clinician will contact you within 1 business day. Please pick this option if you would like to speak with an Ophthalmology clinician prior to referral or just for consultation.

Referral Status(Required)

Emergency Referral

Standard Referral

Phone or Email consult only

How would you like to be contacted?

Phone

Veterinarian to contact(Required)

Prefix First Last

Vet/Clinic Phone Number(Required)

Vet/Clinic Email(Required)

Clinic Name

Clinic Fax Number

Owner Contact Information

Name of Owner(Required)

First Last

Owner Phone(Required)

Owner Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Information about the patient

Patient/Pet Name(Required)

Date of Birth or Age(Required)

Species(Required)

Breed(Required)

Gender

Reason for referral/clinical history (include duration of illness, signs)(Required)

Coggins test current? (equine only)

Please attach to this online form, send via email (ncstateophthalmology@ncsu.edu), or fax (919.513.6711), supporting information, such as eye photos, records, diagnostic test results, or radiographs/ultrasound reports.
Click here for tips on how to take eye photos with your smart phone.

File attachments

Drop files here or

Max. file size: 195 MB.

NC State Estimate provided to owner (if any):

Low: $

High $

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