Referral Form

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- Referral Details
- Date of Referral*
  MM slash DD slash YYYY
- Request*
  - Next available appointment
  - Urgent
  - Emergency
- Referral to:*
  Hold Cmd key (Mac) or Control key (Windows) to select/deselect multiple options.
- Referring Veterinarian Information
- Referring Hospital*
- Veterinarian*
- Phone (Daytime)*
- Phone (After Hours)*
- Fax
- Email*
- Client and Patient Information
- Client First Name*
- Client Last Name*
- Address*
  Street Address Unit # City Province Postal Code
- Phone (home)*
- Phone (work)*
- Phone (cell)*
- Email*
- Have owner or pet been here before?*
  - Yes
  - No
  - Unknown
- Patient Name*
- Species*
- Breed*
- Age*
- Weight*
- Sex*
- Estimated time of arrival if sending patient immediately*
- Tentative Diagnosis / Chief Complaint
- Tentative Diagnosis / Chief Complaint*
  Please describe.
- History / Physical Exam Findings
- History / Physical Exam Findings*
  Please describe.
- Treatments (include medications and dosages)
- Treatments (include medications and dosages)*
  Please describe.
- Laboratory Data Summary
- Laboratory Data Summary
  Please describe.
- Select Laboratory Data Status*
- Radiographs Summary
- Radiographs Summary
  Please describe.
- Select Radiographs Status*
- Special Requests / Comments
- Special Requests / Comments*
  Please describe.
- Pet Vaccination Status
- Rabies*
  - Yes
  - No
  - Unknown
- If yes, year
- Other Vaccination
- Year
- Other Vaccination
- Year
- Other Vaccination
- Year
Phone
This field is for validation purposes and should be left unchanged.

Emergency and Critical Care
- Any Emergency and Critical Care Professional
- Dr. Teresa Cheng
- Dr. Carsten Bandt
- Dr. Kirsty Royle
- Dr. Chris Drolet
Internal Medicine
- Any Internal Medicine Professional
- Dr. Jefferson Manens
- Dr. Lauren Adelman
Neurology
- Any Neurology Professional
- Dr. Nick Sharp
- Dr. Laura Barnard
- Dr. Rachel Lampe
Oncology
- Any Oncology Professional
- Dr. Dianna Saam
Radiology
- Outpatient Abdominal Ultrasound
- Outpatient CT
- Outpatient Radiograph Review
Surgery
- Any Surgery Professional
- Dr. Michael King
- Dr. Willemijn Hoorntje
- Dr. Emma Hall

Referral Details

Referring Veterinarian Information

Client and Patient Information

Tentative Diagnosis / Chief Complaint

History / Physical Exam Findings

Treatments (include medications and dosages)

Laboratory Data Summary

Radiographs Summary

Special Requests / Comments

Pet Vaccination Status