Medical/Surgical Referral Form – Birchwood Animal Hospital

This form is for referrals from VETERINARIANS ONLY. If you are a pet owner seeking a referral, please speak with your routine veterinary care provider to request a referral.

For clients scheduling an appointment (as directed by your routine veterinary provider), please provide the following:

Referring veterinarian’s name.
Referring veterinary practice/facility phone number and email address.
A completed referral form.
Radiographic images and/or laboratory reports.

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Referring Veterinarian's Name

Referring Veterinary Practice/Facility Name

Referring Veterinariam Practice/Facility Phone

Referring Veterinary Practice/ Facility Email

Case Management

Please select one:

Diagnostics only-results returned to referring veterinarian.
Diagnostics with interpretation/examination/procedure

Client Details

Name

First

Last

Phone Number

Alternate Phone Number

Email (if known)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient Details

Patient Name

Species

Breed

DOB/Age

Gender

Coat Colour

Date and type of last vaccination

Date of initial presentation for the problem

Detailed patient history, findings and tentative diagnosis (please include dates)

Current therapy/medications for condition

Other medical conditions or medications/therapy

Additional concerns/considerations

Laboratory Reports

Lab reports attached?

Yes
Already sent
Sending later
No reports

Lab Report #1

Click or drag a file to this area to upload.