Online Doctor Appointment Form

Veterinary Referral Form

Please fill out thefollowing information pertaining to the client and animal you are referring. RVBC will contact the client directly to set up a time for the appointment.
Referring Veterinarian Information
Veterinary Clinic Name
Referring Veterinarian

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Client Information
Owner's name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Patient Information
Pet's name
Date of Birth

DayMonthYear
Estimated age if DOB unknown
Sex
Breed
Colour
Weight (kg)
Date of most recent rabies vaccine

MonthDayYear
Date
Medical History
Please give a brief history of the behavior problem for which you are referring the animal
Please list any treatments (behaviour modification or pharmaceutical/neutraceutical that have been prescribed for this behaviour problem both past a current
Please list any other medical problems and medication/supplements
Please attach any relevant medical records or labwork for this patient. NOTE: CBC,chemistry and free T4 are strongly recommended prior to referral

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Veterinary Referral Form