ROVRS Referral Form

Referral date*

MonthDayYear
Date
Referring Veterinarian Information

Details of the Referring Vet so we can followup
Referring Veterinarian*

First NameLast Name
Referring Veterinary Hospital*
Referring Veterinarian Email*
example@example.com
Referring Veterinarian Phone Number*
Please enter a valid phone number.
Patient Information

Information about the animal being referred
Patient Name
Date of Birth or Age
Species*

CanineFeline
Sex*

MaleFemale
Neutered or Spayed?*

YesNo
Breed*
Colour
Weight (kg)
Patient Temperament
Is the Patient Fed a Raw Diet*

YesNoDon't know
Patient Insurance Company
Medical History & Current Status

Provide a concise but thorough overview of the patient’s relevant medical history and current condition.
Presenting Complaint / Tentative Diagnosis*
History / Physical Exam Findings *
Treatments to date
Diagnostics Performed

List any diagnostic tests already completed and summarize key findings.
Laboratory Tests Performed
Laboratory Data Summary
Radiographs of Affected Area Performed?
Client / Owner Information

Details of the animal’s owner or primary contact.
Owner full name*

First NameLast Name
Owner Email*
example@example.com
Primary phone number*
Please enter a valid phone number.
Secondary phone number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Additional notes or specific questions for the referral team
Medical Records Upload

Upload relevant records such as lab reports, imaging, discharge summaries, and previous medical notes. Multiple files are supported.
Upload patient records (you may upload multiple files)

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Referring Veterinarian Information

Patient Information

Medical History & Current Status

Diagnostics Performed

Client / Owner Information

Medical Records Upload