Specialist Appointment Records Submission – Birchwood Animal Hospital

This form is for veterinary professionals only.

*The form is currently “out of order”, please call 204-832-1368 for instructions*

Veterinarians: Please submit this form AFTER YOU HAVE CONTACTED Great Plains Veterinary Surgery directly to arrange a date and time for the referral service.

*** We do not submit service requests on your behalf as we are one of several facilities where these surgeries and consultations are conducted.

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

Services provided by veterinary specialists are accessible by referral through your routine veterinary care provider after determining whether the patient may further benefit from their focused skills.

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

Please enable JavaScript in your browser to complete this form.

Referring Veterinarian's Name

Referring Veterinary Practice/Facility Name

Referring Veterinariam Practice/Facility Phone

Referring Veterinary Practice/ Facility Email

Appointment already scheduled?

Services

Is this a consultation or surgical procedure?

If this service is provided by Dr. Trevor Bebchuk:

If surgical procedure, please provide details:

Additional Notes

Client Details

Patient Owner's Name

First

Last

Patient Owner's Phone

Patient Owner's Alternate Phone

Patient Owner's 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