Veterinarian Referral Form
Patient Information/History
Pet Name
Breed
Patient Age (in years)
Patient Sex
Please Select
Male Intact
Male Fixed
Female Intact
Female Fixed
Presenting Complaint:
Please provide a concise summary of the patient’s history, pertinent exam findings, recent and relevant diagnostics performed and current medications and dosages. Please do not defer to medical records.
Current/Relevant History & Medications
Please do not defer to medical records.
Client Information
Client Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Veterinary Clinic
Referring Veterinary Clinic
rDVM Name
rDVM Email
example@example.com
rDVM Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you, the referring veterinarian, want this patient to have a full assessment with Dr. Rotaru before any treatments start or would you like to send NS Canine Recovery and Wellness Centre an exact prescription with rehabilitation treatment (if you are opting to send a prescription, we will email you a prescription form)?
Please Select
Full Assessment Please.
Please send the prescription form and I (the referring veterinarian) will take full responsibility of the treatment.
Referral Information
Treatment(s) requested
Rehabilitation Program
Underwater Treadmill (note: if requesting underwater treadmill, please complete the next section)
Acupuncture
Other
Patient Should Be Seen
Next Available Appointment
Priority Appointment
Emergency Appointment
Please Be Aware
That patient will be sent back to the referring veterinarian if diagnostic procedures are needed for building the most effective rehabilitation plan.
Underwater Treadmill Questions
Does the patient have any open wounds and/or incisions?
Yes
No
Does the patient have a draining tract?
Yes
No
Does the patient have a cough and/or fever?
Yes
No
Does this patient have any cardiac diagnosis (ie: Congestive Heart Failure)?
Yes
No
Does the patient have syncope?
Yes
No
Does this patient have a history of seizures?
Yes
No
Does this patient have inadequate perfusion?
Yes
No
Does this patient have a urinary and/or skin infection?
Yes
No
Does the patient have a splint and/or cast that can not be removed?
Yes
No
Does the patient have a urinary and/or IV catheter?
Yes
No
Does the patient have any of the following: Joint/Fracture Instability, Excessive Muscle Weakness, Ruptured or Weak Tendons/Ligaments?
Yes
No
Does this patient have Unmanaged Pain/Joint Inflammation, Levelling Ostomies?
Yes
No
Is this patient able to support their head/neck?
Yes
No
Is the patient pregnant?
Yes
No
Male Patient
If you have answered yes to any of the above questions, please explain.
Relevant Documents (Please include all relevant x-rays)
Documents Included: (select all that apply)
Relevant Medical Records
Lab Results
Radiographs
Other
Documents Will Be Sent Via:
Uploaded
PACS (preferred for Radiographs)
Courier
Other
File Upload
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Additional Comments About This Referral
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