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.Format: (000) 000-0000.
Are you this patient's primary care provider?
If no, please list the patient's primary care veterinary hospital and provider (if known)
Patient Information

Information about the animal being referred
Patient Name
Date of Birth or Age
Species
Sex
Neutered or Spayed?
Breed
Colour
Weight (kg)
Patient Temperament
Is the Patient Fed a Raw Diet
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.Format: (000) 000-0000.
Secondary phone number
Please enter a valid phone number.Format: (000) 000-0000.
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.
Acknowledgment – Specialist Referral Notification

If additional specialty care is recommended, ROVRS may refer your patient to another Board Certified specialist. Please indicate whether you would like to be notified before we initiate any such referral.
Would you like to be notified?
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