Canandaigua Veterinary Hospital Surgical Referral Form
1. Referral Type
*
Thrive Network Hospital
Non-Thrive External Hospital
Date of Referral
*
-
Month
-
Day
Year
Date
Referring DVM Name
*
Referring Hospital Name
*
Referring Hospital Phone Number & Email
*
Client Name
*
Client Phone Number & Email
*
Patient Name
*
Species
*
Canine
Feline
Patient Breed
*
Age/DOB
*
Weight (lbs)
*
Vetspire ID (If applicable)
Patient is current on wellness exam and vaccines
Yes
No
Patient is current on heartworm prevention
Yes
No
Pre-Surgical Bloodwork Performed within 30 Days
*
Attached
To be preformed at CVH pending consult
Scheduled for later date at rDVM Hospital
Surgical Concern/Diagnosis
*
Requested Procedure
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FHO
MPL
Ex-Cap Repair
Growth Removal
Amputation
Cherry Eye
Enucleation
Entropion
Cystotomy
Gastropexy
Splenectomy
Abdominal Exploratory
Foreign Body Removal/R&A
Umbilical/Abdominal Hernia Repair
Mastectomy
Pyometrectomy
Symphyseal Jaw Fracture Repair
Laceration Repair
Stenotic Nares Repair
Scrotal urethrostomy
Perineal urethrostomy
Anal sacculectomy
Episioplasty
Imaging is completed, Required for referral
*
Yes
No
Complete Medical Records and Imaging have been sent to Canandaigua.info@thrivepet.com
*
Yes
No
Preferred Timeline for Evaluation
*
Urgent Referral (1-2 weeks)
Non-Urgent Referral
Submit
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