McKnight VH - Patient Referral Form

Patient Referral Form

Referral Instructions: When referring your patient to McKnight 24 Hour Veterinary Hospital, please complete this online submission form. All pertinent medical records can be uploaded through this form or submitted via email to info@mcknightveterinaryhospital.ca.
DATE

Month Day Year
Date
REFERRING VETERINARIAN INFORMATION
REFERRING HOSPITAL
rDVM NAME
PHONE NUMBER

Area Code Phone Number
FAX NUMBER

Area Code Phone Number
CELL NUMBER

Area Code Phone Number
EMAIL
example@example.com
Please indicate which number is your preferred method of contact.
Does your client know that you are sending this referral?
CLIENT INFORMATION
OWNER'S NAME

First Name Last Name
CO-OWNER'S NAME

First Name Last Name
ADDRESS

Street Address

Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER

Area Code Phone Number
SECONDARY PHONE NUMBER

Area Code Phone Number
EMAIL
example@example.com
PATIENT INFORMATION
PET NAME
AGE/D.O.B
SPECIES/BREED
GENDER
WEIGHT
COLOUR
REASON FOR REFERRAL

No appointments available We are closed/closing Patient needs overnight monitoring
PATIENT IS

Critical Stable Healthy
MEDICAL HISTORY
Please provide all information including exam findings, diagnostics performed, treatment and current medications/dosages.
DOCUMENTS

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

Browse Files

Cancel of
LAB SAMPLES

Coming with the client Not collected yet Completed and attached
X-RAYS

Coming with the client Not performed yet Emailed separately to info@mcknightveterinaryhospital.ca
CHECKLIST

Medical records have been sent to McKnight VH An estimate has been prepared for the client by McKnight VH, they have signed and it has been sent back McKnight has been called and notified of estimated time of arrival Client has been informed that if the animal is stable and McKnight has another critical patient, there may be a wait
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:

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

DOCUMENTS