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.

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 *