Rehabilitation Referral Form

*Please note this form is for referring veterinarians only. If you would like a referral, please contact your regular family veterinarian.

REFERRING VETS: When referring your patient to our hospital, please complete this form and upload all pertinent medical records.

Hillside Veterinary Hospital reserves the right to discontinue services if appointments are repeatedly missed without notice.
Please ensure any referred clients are made aware of this policy prior to referral.

REFERRING VETERINARIAN INFORMATION

Name of Referring Veterinarian *

Hospital/Clinic Name *

Hospital/Clinic Phone Number *

Hospital/Clinic Email Address *

OWNER INFORMATION

Full Name *

Name of secondary contact and/or spouse

Address *

City *

Province *

Postal Code *

Phone Number*

Email Address *

PATIENT INFORMATION

Patient's Name *

Species *

Breed *

Temperament *

Sex *

Age *

In months/years, or birthdate

Colour / Markings *

Weight *

In kg

REQUIRED DOCUMENTATION / INFORMATION

Reason For Referral *

Diagnostic procedures performed/planned, include dates, please send all relevant imaging *

Treatments/Surgeries with dates *

Current medications, supplements

Additional Comments

Upload Required Documentation (medical records, lab work, imaging, etc): *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *