Panoquell Referral Form

Referring Clinic Information

Clinic Name

Referring Veterinarian

Phone Number

Client Information

Owner Name

Phone Number

Patient Information

Name

Species/Breed

Age

Sex

Weight

Clinical Summary

Diagnosis / Rule-outs

Presenting signs

Duration of illness

Diagnostics Performed

Diagnostics Performed (Attach records)

CBC/Chem

cPL / Pancreatitis test

Imaging

Other

Other Diagnostics Performed

Please upload any relevant diagnostic records, test results, or imaging reports

Choose File

Treatment to Date

Panoquell

Dose given

Date/time of last dose

Day of therapy (circle)

Requested Service

Initiate Panoquell therapy

Continue Panoquell (Day ___ of 3)

Weekend continuation only

Supportive care as needed

Special Instructions / Notes

Acknowledgment

I understand that:
• Specialized Veterinary Care will provide limited continuation of care
• Primary case management remains with the referring clinic
• Communication will occur following treatment

Date

Holiday Notice:

Online Prescription Policy Effective August 1, 2026

Transfer of Care Form