Download Referral Form

Is this a Referral to
Emergency Service?
www.westernvet.ca
1802 - 10th Ave S.W. Calgary, AB T3C 0J8
Phone: (403) 770-1340 Toll Free: 1-866-770-1340
Fax: (403)770-1344
[email protected]
(If yes, please check)
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

 Critical Care
Madden
 Val
DVM

 Jenefer Stillion
DVM

 Cardiology
Etienne Cote

DVM

 Ophthalmology
 Kelli Ramey
DVM

 Internal Medicine
Debra Henderson
 BSc. DVM
Diplomate American College of
Veterinary Emergency & Critical
Care
Diplomate American College of
Veterinary Emergency & Critical
Care
Diplomate American College of
Veterinary Internal Medicine
(Cardiology)
Diplomate American College of
Veterinary Ophthalmology
(also available online at www.westernvet.ca)
Owner Information:
Primary Phone:
(
Client Name:
)
Patient Information:
Sex:
F
FS
Today’s Date: ___________________
M
Additional:
Patient Name:
MN
(
)
Breed:
Date of Birth:
Referring Veterinarian Information:
mm / dd / yyyy
kg
Weight:
Hospital Name:
Veterinarian:
Phone:
Fax:
Email:
Other veterinarians involved in this case:
Please indicate how you are sending the following:
Referral Form
E-mail or Online
Fax
With Client
Courier
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













Diplomate American College of
Veterinary Internal Medicine
Relevant Medical Records
DVM
Radiographs
Diplomate American College of
Veterinary Internal Medicine
History and Physical Finding: _________________________________________________________
Chantal McMillan


 Oncology

Glenna Mauldin
 DVM, MS

Diplomate American College of
Veterinary Internal Medicine
(Oncology)

Patient Referral Form
Neal Mauldin
 DVM
 Rehabilitation

Caroline Dahlen
Certified in Canine
 DVM,
Rehabilitation Therapy
 Surgery
Tamara MacDonald
 DVM
 Bronwyn Fullagar
 BVSc, MS
 Terri Schiller
 DVM
 Radiology
Rousset
 Nic
BVSc


Diplomate American College of
Veterinary Radiology (Radiation
Oncology)
Diplomate American College of
Veterinary Surgeons
Diplomate American College of
Veterinary Surgeons
Diplomate American College of
Veterinary Surgeons
Diplomate European College of
Veterinary Diagnostic Imaging

Lab Results
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Laboratory / Radiographic / Biopsy Information: _________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Has the client been given an estimated fee for services?
YES
NO
If so, how much was quoted? ___________________________________________________________
Outpatient Radiology (please incl history and other info in space above)
 Ultrasound
If sedation is necessary or a biopsy is indicated, I approve a pre-sedation evaluation and management of the
case by the appropriate department while the patient is in our care. CBC / chem & coagulation profile may be
required if not obtained in the last 2 weeks.
YES
NO
(please circle one)
 CT Study Requested ________________________ (requires CBC, chem, UA & PE within 2 wks)
 Radiographic Interpretation (please email DICOM images to [email protected])