Referral Form
When referring your patient to our hospital, please complete this form and upload all pertinent medical records.
Please select the type of referral:
*
Please Select
Radioactive Iodine Therapy
Referring Veterinarian Information
Hospital Name
*
Clinic/Hospital Phone Number
*
Please enter a valid phone number.
Clinic/Hospital Fax Number
Please enter a valid fax number.
Clinic/Hospital Email
*
example@example.com
Referring Veterinarian
*
First Name
Last Name
Client Information
Name
*
First Name
Last Name
Name of secondary contact and/or spouse:
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Patient Information
Name
*
Birth Date
*
-
Month
-
Day
Year
Approximate
Age
*
In months/years, or birthdate
Species
*
Breed
*
Colour / Markings
*
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
Weight:
*
In kg
Other comorbidities (besides hyperthyroidism)
Temperament (shy, outgoing, fractious, etc.)
Required documentation / information
Date of diagnosis
*
-
Month
-
Day
Year
Date
Medication type & dosage
*
Is your patient eating Y/D food?
*
Yes
No
Chem 15/CBC/Lytes
*
Yes
No
T4 Level (off medications)
*
T4 Level measured
*
in hospital
in reference lab
Upload Medical Records
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
*
I understand that Petworks Veterinary Hospital has an extensive waitlist and clients will be contacted to arrange a phone consultation
approximately a month before when possible treatment will be.
*
I understand that
if the status of the patient changes after this referral form is submitted, it is my responsibility to update Petworks Veterinary Hospital about any changes
and/or to cancel the referral.
Is the client unsure if treatment is the right fit? Please let us know so we can manage appropriately.
The client is unsure of treatment
The client is fully supportive of treatment
Neutral / I don't know
Additional Information / Comments:
Submit
Should be Empty: