4 Paws - Patient Referral Form

Patient Referral Form

Dr. Kathryn Sykes | Dr. Kip Grasse | Dr. Stephanie Hayward | Dr. Brittni Milligan | Dr. Karl Mitchell | Dr. Hannah Porter | Dr.Susi Brown | Dr. Erin Cambier | Dr. Patrick Boelsterli

When referring your patient to our hospital, please complete this form along with all pertinent medical records. If this is an emergency which requires treatment within 24 hours, please contact our Emergency Team directly 902.225.7543. For emergencies press option 1, for stable patients press option 2
DATE

MonthDayYear
Date
REFERRING VETERINARIAN INFORMATION
REFERRING HOSPITAL
rDVM NAME
PHONE NUMBER

Area CodePhone Number
FAX NUMBER

Area CodePhone Number
CELL NUMBER

Area CodePhone Number
EMAIL
example@example.com
Please indicate which number is your preferred method of contact.
CLIENT INFORMATION
OWNER'S NAME

First NameLast Name
CO-OWNER'S NAME

First NameLast Name
ADDRESS

Street Address

Address Line 2

CityState / Province

Postal / Zip Code
BEST TIME TO CONTACT CLIENT
if no preference, please write "anytime"
PHONE NUMBER

Area CodePhone Number
SECONDARY PHONE NUMBER

Area CodePhone Number
EMAIL
example@example.com
PATIENT INFORMATION
PET NAME
AGE/D.O.B
SPECIES/BREED
GENDER
WEIGHT
COLOUR
PATIENT IS

CriticalStableHealthy
REFERRAL REASON

Unable to accommodate appointmentOvernight hospitalization/critical care
CASE SUMMARY
PROPOSED TREATMENT PLAN
Please provide all information including exam findings, diagnostics performed, and attached current treatment information.
UPLOAD TREATMENT FILES

Browse Files

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DOCUMENTS

Please upload any information such as medical records, treatment sheets, images, lab results, or additional sheets.
UPLOAD FILES HERE

Browse Files

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CHECKLIST

Medical records are attached to this submission form.Client is aware of exam fee and that a treatment plan will be reviewed at admission.4PAWS has been called and notified of estimated time of arrival.Client has been informed that if the animal is stable and 4Paws has another critical patient, there may be a wait.
LAB SAMPLES

Coming with clientNot collected yetCompleted and attached
X-RAYS

Not performed yetEmailed to info@4pawsveterinaryhospital.com
Thank you for taking the time to complete this form. A member of our team will be in contact with you as soon as possible.
Should be Empty:

Patient Referral Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

DOCUMENTS