Referral Form for Veterinarians – Hillside Veterinary Hospital

Rehabilitation Referral Form for Veterinarians

To download and print a Referral Form click here or fill out and submit our online form below. If you are not the pet's regular veterinarian, please include their name as well as your own. Please note, medical history, relevant imaging and laboratory results must be received before we will contact a client and book their appointment. Please send related medical records and X-rays to [email protected] or fax them to 250-598-7740.

Referring Veterinarian Information
Date
Date Format: MM slash DD slash YYYY
Referring Veterinarian*
First Last
Clinic/Hopsital*
Phone*
Fax*
Veterinarian Email*
Please check reason for referral
- Mobility Assessment/Rehabilitation - General/Lameness
- Mobility Assessment/Post Surgical Rehabilitation
- Mobility Assessment/Conditioning/Sporting
- Mobility Assessment/Rehabilitation - Neurologic
- Acupuncture - Dr. Jennifer Chan
- Chiropractic - Dr. Glynis Newman, Dr. Sylvie Abrioux, Dr. Kevin Keller
- This referral is for an urgent concern
Client Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone*
Home Phone*
Client's Preferred Contact #*
Patient Information
Patient*
Species*
Breed
Colour
Sex
Birth Date
Temperment
Medical Condition
Primary Concern and/or Tentative Diagnosis
Recent Radiographs?
If yes, please forward to [email protected]
Recent Laboratory?
If yes, please forward to [email protected]
Consent to perform diagnostics?
Hillside Veterinary Hospital may proceed with any necessary diagnostics that a Rehabilitation Veterinarian may recommend (Radiographs, laboratory work, etc.), upon owners consent.
Related Surgical and/or Other Procedures Performed (include dates)
Injury Summary
Please email relevant records to [email protected]
Current Medications and Dosages
Current Supplements
Any known concerns or contraindications to rehabilitation modalities?

Rehabilitation Referral Form for Veterinarians

Referring Veterinarian Information

Client Information

Patient Information

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