Referral Form

REFERRING HOSPITAL INFORMATION

Referring Veterinary Hospital

Referring Veterinarian

rDVM Phone Number

rDVM Email

Has this patient been seen at any other veterinary hospitals/clinics in the last 2 years?

Yes

CLIENT INFORMATION (only needs to be completed if we will be contacting the client)

Client First Name

Client Last Name

Client Phone Number

Client Email Address

Client Address

PATIENT INFORMATION

Patient Name

Species/Breed

Date of Birth

Sex

Weight (kg)

VETERINARY HISTORY (Please provide as detailed of a summary as possible. Deferral to medical records may result in a delay of the referral process.)

Reason for Referral

Relevant Medical History

Treatments/interventions performed to date

Current medications

Patient should be seen

Next available appointment

Priority appointment (if available)

Emergency (please call)

ADDITIONAL INFORMATION

Patient Temperment

Additional comments/concerns, or anything else you feel would be helpful with this case

If additional testing is recommended, can it be performed at Macleod Trail Animal Hospital without first contacting you?

Yes

If Dr. Jones feels this case would benefit from referral to another specialist, can this be offered to the client without contacting you prior?

Yes

MEDICAL RECORDS

Please indicate how you are sending the following:

Medical Records

Lab Results

Radiographs

Upload files here

403-255-1168

office@mactrailvet.com

MACLEOD TRAIL
ANIMAL HOSPITAL

Referral Form