Clone of CAPs Referral Form

CAPs Patient Referral Form

To be filled out by the patient's regular veterinarian. Fields marked with a * are required.
CLIENT INFORMATION
Client (owner/agent) Name:*

First NameLast Name
Alternate Contact if Applicable:

First NameLast Name
Main Phone Contact:*
Please enter a valid phone number.
Alternate Phone Contact:
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PATIENT INFORMATION
Patient Name:*
Species:*
Breed:*
Age:*
Sex:*
For the safety of our team and patients, all pets entering the rehab facility are required to be up to date on the following vaccinations:
Is the patient up to date on Rabies vaccination?*
Is the patient up to date on Distemper, Adenovirus, Parvo Vaccination (DAP or DAPP?)*
Is the patient up to date on Bordetella (Kennel Cough) Vaccination?*
If feline, is the patient up to date on Herpesvirus, Calivirus and Panleukopenia?
Please indicate the primary reason for referral (ex, prehab pre-surgery, post-surgical rehab, orthopedic disease, conditioning, weight-loss, other). If post-surgical, please indicate the procedure and which limb or area of the body is involved:
Does the patient exhibit fear, anxiety or stress in-clinic or in new environments?
Is muzzling recommended for handling procedures?
Additional comments regarding pet's behaviour, interactions or handling, or other information you want us to know:
FIT TO SWIM SECTION

As most patients entering our rehab program will likely be utlilizing our hydrotherapy modalities including the underwater treadmill and/or hydrotherapy pool, we require the following information for the safety of the patient.

Does the patient have any of the underlying health issues?
Heart Murmur or clinical signs of heart Disease? (syncope, elevated SRR, cough etc.)
If yes, please describe:
If applicable, has the heart murmur been worked-up or staged? (ex. chest rads, echocardiogram, ECG?)
If applicable, is the patient on heart medications? If so, what meds and dosage?
Any history or seizures or other neurological conditions?
If yes, please explain including any medications for these conditions.
Upper and/or Lower Respiratory Disease?
If yes, please explain including any medications for these conditions.
Acute or Chronic skin conditions?
If yes, please explain including any medications for these conditions.
History of fecal and/or urinary incontinence?
If yes, please explain including any medications:
List any medications or supplements prescribed not already listed:
Please send all relevant medical history including recent radiographs or surgical reports pertaining to the condition. PLEASE NOTE: CAPs will only be treating conditions pertaining to the reason for referral. All other medical issues and need for tests will be referred back to the regular veterinarian, unless requested by the referring veterinarian to do otherwise. We will forward all records of your patient's visits with us. Primary care will remain with the referring veterinarian.

REFERRING VETERINARIAN INFORMATION
Date*

MonthDayYear
Date
Referring Veterinarian Name:*

First NameLast Name
Veterinary Hospital:*
Phone Number*
Please enter a valid phone number.
Email:*
example@example.com
Town/City, Province:
Signature*

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Collingwood Active Pets

come.swim.heal.

2823 Concession 7 (back of Mountain Vista Veterinary Hospital off Poplar Sideroad)

Collingwood, Ontario

L9Y 3Z1

P: 705 446-0261 select line:6

F: 705 441-1684

e-mail: CAPS@mvvh.ca

www.mountainvistavet.com
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CAPs Patient Referral Form