Petworks Veterinary Hospital - Referral Form

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: *

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

Required documentation / information
Affected Limb: *

Left Right Bilateral Front Hind
Tentative Diagnosis: *
Present Complaint: *
Required documentation:
- Pre-Anesthetic Bloodwork (Chem 15/CBC/Lytes)
- Complete medical records
- Radiographs
Please note that we have started performing bloodwork on the morning of surgery for many of our procedures. Bloodwork done ahead of time at the regular clinic will be reviewed by the surgeon and is still recommended to rule out other comorbidities.
Upload Required Documentation: *

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