Referral Form Referral Form This form is also available as a fillable PDF. Download Referral DetailsDate of Referral* MM slash DD slash YYYY Request* Next available appointment Urgent Emergency Referral to:*Emergency and Critical Care- Any Emergency and Critical Care Professional- Dr. Teresa Cheng- Dr. Carsten Bandt- Dr. Kirsty Royle- Dr. Chris DroletInternal Medicine- Any Internal Medicine Professional- Dr. Jefferson Manens- Dr. Lauren AdelmanNeurology- Any Neurology Professional- Dr. Nick Sharp- Dr. Rachel LampeOncology- Any Oncology Professional- Dr. Tien Tien- Dr. Dianna SaamRadiology- Outpatient Abdominal Ultrasound- Outpatient CT- Outpatient Radiograph ReviewSurgery- Any Surgery Professional- Dr. Michael King- Dr. Willemijn Hoorntje- Dr. Emma Hall-Dr. Jo Anne Au YongHold Cmd key (Mac) or Control key (Windows) to select/deselect multiple options.Referring Veterinarian InformationReferring Hospital* Veterinarian* Phone (Daytime)*Phone (After Hours)*FaxEmail* Client and Patient InformationClient First Name* Client Last Name* Address* Street Address Unit # City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 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*Please chooseFFSMMNEstimated time of arrival if sending patient immediately* Tentative Diagnosis / Chief ComplaintTentative Diagnosis / Chief Complaint*Please describe.History / Physical Exam FindingsHistory / Physical Exam Findings*Please describe.Treatments (include medications and dosages)Treatments (include medications and dosages)*Please describe.Laboratory Data SummaryLaboratory Data SummaryPlease describe.Select Laboratory Data Status*Please chooseComing with ownerSent via emailFaxedNot doneRadiographs SummaryRadiographs SummaryPlease describe.Select Radiographs Status*Please chooseComing with ownerSent via email/PACSFaxedNot doneSpecial Requests / CommentsSpecial Requests / Comments*Please describe.Pet Vaccination StatusRabies* Yes No Unknown If yes, year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000Other Vaccination Year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000Other Vaccination Year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000Other Vaccination Year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000NameThis field is for validation purposes and should be left unchanged.