Medical/Surgical Referral – Birchwood Animal Hospital

This form is for referrals from veterinarians only.

PLEASE NOTE: If you are a pet owner seeking a referral, please speak with your routine veterinary care provider.
We cannot respond to referrals from non-veterinarians.

Referred clients scheduling appointment must provide the following:

* Referring veterinarian’s name

* Referring veterinary practice / facility phone number and address

* A completed referral form, radiographic images and / or laboratory reports

Veterinarians: Please complete the following for consultations and / or procedures conducted on our premises.

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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.