Referral Form
Type of referral
*
Surgery - Direct surgical consultation required
Outpatient Imaging - No consultation with client, referring veterinarians will receive the radiology report and make clinical decisions.
Inpatient Imaging - Full surgical consultation with client following imaging appointment.
Date
-
Month
-
Day
Year
Date
Referring Veterinarian Information
Referring Hospital
*
Please Select
Admirals Walk Pet Clinic
Agwest Veterinary Group
Align Vet Services
Applecross Veterinary Hospital
Arrowsmith Animal Hospital
Balanced Paws Veterinary Care
Beacon Pet Hospital
Bellevue Veterinary Hospital
Belmont Langford Veterinary Hospital
Benson View Veterinary Hospital
Breadner Veterinary Services
Brentwood Bay Veterinary Services
Broadmead Village Veterinary Clinic
Campbell River Animal Hospital
Capital Cat Clinic
Central Cowichan Animal Hospital
Central Island Veterinary Hospital (Emergency)
Central Saanich Animal Hospital
Central Victoria Veterinary Hospital (Emergency)
Chase River Veterinary Hospital
Chemainus Animal Hospital
City Pets Animal Clinic
Clinic for Cats
Clover Point Veterinary Rehab Clinic
Coastal City Animal Hospital
Coastland Veterinary Hospital
Cobble Hill Animal Hospital
Comox Valley Animal Hospital
Country Animal Hospital
Countryside Pet Hospital
Courtenay Veterinary Clinic
Cumberland Veterinary Clinic
Dean Park Pet Hospital
Departure Bay Veterinary Hospital
Dogwood Veterinary Hospital
Downtown Veterinary Clinic
Duncan Animal Hospital
Duncan Cat Clinic
Eagle Rise Animal Hospital
Elk Lake Veterinary Hospital
Evergreen Dentistry Veterinary Services
Fantastic Beasts Veterinary Services- Parksville
Fantastic Beasts Veterinary Services - Nanaimo
Feltham Animal Hospital
Fernwood Veterinary Clinic
Garry Oak Veterinary Hospital
Glenview Animal Hospital
Grace Veterinary Hospital
Harbour City Animal Hospital
Haida Gwaii Animal Hospital
Helmcken Veterinary Clinic
Hammond Bay Animal Hospital
Heritage Veterinary Clinic
Hillside Veterinary Hospital
i-Care Veterinary Hospital
Island Animal Hospital
Island Tides Veterinary Hospital
Island Veterinary Eye Specialist
James Bay Veterinary Clinic
Juan De Fuca Vet
Kindred Spirits Veterinary Hospital
Kinsol Veterinary Clinic
Lifeline Animal Clinic
Lighthouse Veterinary Clinic
Linley Valley Veterinary Clinic
Mahalo Veterinary Hospital (Urgent Care/After Hours Emergency)
Manzini Animal Hospital
McKenzie Veterinary Services
Merecroft Veterinary Clinic
Mid-Isle Veterinary Hospital
Mill Bay Veterinary Services
Millstream Veterinary Hospital
Nanaimo Veterinary Hospital
North Island Veterinary Hospital
Oak Bay Pet Clinic
Oaklands Veterinary Hospital
Oceanside Animal Hospital
Otter Point Veterinary Hospital
Pacific Animal Wellness Services
Pacific Cat Clinic
Padfoot Animal Hospital
Parksville Animal Hospital
Petroglyph Animal Hospital
Port McNeill Veterinary Clinic
Prevost Vet Clinic
Puntledge Veterinary Clinic Inc.
Qualicum Beach Animal Hospital
RainTree Veterinary Hospital
Ross Bay Animal Hospital
Royal Oak Vet Clinic
Saanichton Village Veterinary Hospital
Salt Spring Veterinary Service
Saseenos Veterinary Services
Seaside Veterinary Care
Sidney Animal Hospital
Sitka Veterinary Services
Sooke Veterinary Hospital
Sunrise Veterinary Clinic
Thetis Heights Veterinary Clinic
Tofino Vet Clinic
Tsolum Veterinary Hospital
Van Isle Veterinary Hospital
Vancouver Island Veterinary Surgery
VCA Ladysmith Animal Hospital
VCA Shamrock Animal Hospital
Vic West Pet Hospital
Warmland Animal Clinic
WAVES Veterinary Hospital (Emergency)
Westshore Pet Clinic
Westview Veterinary Hospital
Woodgrove Animal Hospital
OTHER - Please specify below
Referring Hospital Not Listed Above
Are you the Primary Care Veterinarian?
*
Yes
No
If you are not the Primary Care Veterinarian, please list below:
Referring Veterinarian
*
Dr.
Prefix
First Name
Last Name
Primary Care Vet Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Information
Patient Name
*
Patient Date of Birth
*
/
Day
/
Month
Year
Date
Species
*
Canine
Feline
Other
Sex
*
Male, castrated
Female, spayed
Male, intact
Female, intact
Unknown
Weight in KG
*
KG only please
Breed
*
Colour
*
Temperament
*
Please Select
Friendly
Anxious
Aggressive
Quiet
Fearful
If appropriate, please prescribe the patient trazodone and/or gabapentin for clients to administer prior to surgical appointments.
Is this patient raw fed?
*
Yes
No
Is this patient insured?
*
Yes
No
Presenting Complaint
What is the primary problem/s?
*
Listed form is preferred
Relevant History
*
Provide a succinct and clear history of the primary problem/s
Current Medications
*
Please provide doses for all medications
Recent diagnostics
*
CBC
Chem
Radiographs
Ultrasound
FNA
None
Biopsy
Other
Client Information
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number - Primary
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number - Secondary
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email
*
example@example.com
Patient records
Please upload the records using the file upload field or email us directly.
Records being sent via
*
Please Select
Upload box below
Emailed to info@orcavet.ca
File Upload
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*
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