Carstairs Vet Services - Patient Referral Form

Patient Referral Form

When referring your patient to our hospital, please complete this form along with all pertinent medical records. Also, please ensure that you contact the doctor that will be managing the case at Carstairs Veterinary Clinic to ensure continuity of care.
Referring Veterinarian Information
Name of Referring Veterinarian: *
Name of Referring Hospital: *
Phone Number: *

Area Code Phone Number
Fax Number: *

Area Code Phone Number
Email Address of Referring Veterinarian: *
example@example.com
Best Time to Contact:
Client Information
Client's Name: *

First Name Last Name
Client's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Client's Phone Number: *

Area Code Phone Number
Client's Email: *
example@example.com
Patient Information
Patient's Name: *
Breed: *
Date of Birth: *

Month Day Year
Date
Sex: *

Male Female
Neutered/Spayed: *

Yes No
Colour: *
Weight: *
Patient is: *

URGENT NON-URGENT
Referral Reason: *

Orthopedics General Surgery
Case Summary - Please include all significant findings and working Diagnosis: *
Lab Samples: *

Not Collected Yet Completed (attach the records below)
X-Rays: *

Not Performed Yet X-Ray Images and Radiology Report (attach below)
Patient's Medical Records (Please attach the full medical records including lab samples, X-rays, and reports.) *

Browse Files

Cancel of
Wait Time Acknowledgment: *
Pre-Scheduled Appointment Acknowledgment: *
Carstairs Veterinary Clinic will not be contacting the owner of the referred patient until all medical records are received.
Should be Empty:

Patient Referral Form

Referring Veterinarian Information

Client Information

Patient Information