Campbell River VH - Surgery Referral Form

Surgery Referral Form

Referral Instructions: When referring your patient to Campbell River Veterinary Hospital, please complete this online submission form. All pertinent medical records can be uploaded through this form or submitted via email to info@campbellrivervet.com.

Please note that a $500 dollar booking fee is required for all referral surgeries. It is refundable up until 48 hours before your appointment date.
DATE

MonthDayYear
Date
REFERRING VETERINARIAN INFORMATION
Referring Hospital*
Veterinarian Name*
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email*
example@example.com
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
Phone Number*

Area CodePhone Number
Email*
example@example.com
PATIENT INFORMATION
Pet's Name*
Breed*
Age*
Colour*
Current Weight*
Gender*
Presenting Complaint/Diagnoses:*
History:
Current Medications/Dosages:
DOCUMENTS

Test results and all pertinent medical records can be uploaded through this form or sent via email to info@campbellrivervet.com.
UPLOAD FILES HERE

Browse Files

Cancelof
DOCUMENTS INCLUDED*

Total Body Chemistry PanelSDMA4DxCBC CompleteUrinalysisRadiographsOther
YOUR DOCUMENTS WILL BE SENT BY*

UploadedEmail
We are happy to answer any questions you may have. Thank you for entrusting us with the care of your pet.
Should be Empty:

Surgery Referral Form