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Refer a Patient
Self Referral
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Financing
Contact
Self Referral
Refer a Client
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Refer a Patient
Self Referral
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Refer a Patient
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Vet Referral
Patient Information
Pet Name
(Required)
Age
(Required)
please specify if age is in years or month
in YEARS
in MONTHS
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
M
M (n)
F
F (s)
Species / Breed
(Required)
Weight (kg)
(Required)
Colour
(Required)
Client Information
Client Name
(Required)
First
Last
Primary Client Phone
(Required)
Secondary Client Phone
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Referring Hospital Information
Referring Hospital
(Required)
rDVM Phone
(Required)
rDVM Name
(Required)
First
Last
rDVM Email
(Required)
Is this an emergency?
Yes
No
Your Patient's Medical History
Please included patient history, medical findings, images, or other files.
Documents Included:
(Required)
Medical Records
Lab Results
Radiographs
None
Other
Other Documents
(Required)
Upload File(s) Here
Drop files here or
Select files
Accepted file types: pdf, doc, docx, jpg, gif, png, Max. file size: 2 MB.
Documents Will Be Sent Via
(Required)
Uploaded
FTP / URL
with Client
PACS (Preferred for X-Ray)
Courier
Other
Other Method
(Required)
Presenting Concern
(Required)
Health Status & Medications
(Required)
Include behavioural concerns, medical alerts, or history of seizures or drug reactions. Please include your clinical findings and impressions of the case, any recent laboratory tests, imaging findings etc. These can be uploaded.
Current Diet
(Required)
Current Medication
(Required)
Has muzzling or sedation been required for examination of this patient?
(Required)
Yes
No
I consent to the use and storage of my information in accordance with the terms and conditions detailed in the privacy statement.
(Required)
I consent to the use and storage of my information in accordance with the terms and conditions detailed in the
privacy statement
.
I agree to the terms and conditions
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