Bridgwater VH - Patient Transfer Form

Patient Transfer Form

If you are a client’s regular veterinarian and wish to transfer a patient to Bridgwater Veterinary Hospital & Wellness Centre for overnight care, further diagnostics, or other, please complete this form.

If you have any questions about the referral of specific cases, feel free to phone ahead and speak to one of our veterinarians.

Note: If a patient is stable when the referring veterinary hospital reopens, the patient’s transfer will be arranged at request. Patient transportation is an owner’s responsibility. If a patient is not stable for transfer, they will remain in care at Bridgwater Veterinary Hospital and Wellness Centre.
DATE

MonthDayYear
Date
REFERRING VETERINARIAN INFORMATION
REFERRING HOSPITAL
rDVM NAME
PHONE NUMBER

Area CodePhone Number
FAX NUMBER

Area CodePhone Number
EMAIL
example@example.com
PATIENT INFORMATION
PET NAME
AGE
SPECIES/BREED
GENDER
WEIGHT
COLOUR
PATIENT NOTES (i.e. Caution)
PATIENT IS

CriticalStable
REFERRAL REASON

Patient is criticalPossible surgical intervention requiredPatient needs 24 hr care
PRESENTING COMPLAINT
CURRENT/RELEVANT HISTORY & MEDICATION
Please provide all information including exam findings, diagnostics performed, and current medications/dosages.
CBC
CHEMISTRY
ELECTROLYTES
BLOOD GAS
T4
CPL/FPL
UA
TENTATIVE DIAGNOSIS
DRUGS GIVEN | DOSE/ROUTE | FREQUENCY | TIME GIVEN | NEXT DOSE DUE
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
SECONDARY PHONE NUMBER

Area CodePhone Number
EMAIL
example@example.com
DOCUMENTS

All records must be received prior to the patient's arrival.
UPLOAD FILES HERE

Browse Files

Cancelof
LAB SAMPLES

Coming with clientNot collected yetCompleted and attached
X-RAYS

Coming with clientNot performed yetCompleted and sent
DOCUMENTS INCLUDED

Medical RecordsLab ResultsRadiographsOther
YOUR DOCUMENTS WILL BE SENT BY

UploadedPACS (Preferred by x-ray)EmailFax
CHECKLIST

Medical records have been uploaded/sentAn estimate has been prepared for the client by Bridgwater VH, they have signed and it has been sent backBridgwater VH has been called and notified of estimated time of arrivalClient has been informed that if the animal is stable and Bridgwater VH has another critical patient, there may be a wait
SPECIAL REQUESTS AND ADDITIONAL COMMENTS
Is the patient being transferred back to your facility?

YESNO
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

PATIENT INFORMATION

CLIENT INFORMATION

DOCUMENTS