Referral Form

Referral Form
If this is an emergency or your patient needs to be referred after hours or on weekends, please do not fill out this form, instead email the records to hospital@cwaeh.ca and please call the clinic at 403-347-2676 and press 1 for our emergency department.
SurgeryUltrasoundDermatologyRehabilitationReproduction
please call us at 403-347-2676 and press 1 for the emergency department.
Dr. Graham KeysDr. Dagmar SchoutenDr. Tara DixonNo Doctor PreferenceOther
Date*

MonthDayYear
Reason for Referral*
Referring Clinic*
Referring Doctor*
Would you like us to contact the client to set up the referral or contact your clinic?*
Client Details
Client Name*
Contact Number*
Format: (000) 000-0000.
Email*
E-MailFaxUploaded
Pet Information
Patient Name*
Breed*
DOB*

MonthDayYear
Date
Sex*
History/Presenting Problem/Physical Exam
Diagnostics/Treatments Performed: Upload Documents (Send us patient files, lab work, radiographs, etc.)
EMR sent to referring clinic
Upload Documents or email documents to referral@cedarwoodvet.ca

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