REFERRAL REQUEST - SURREY (BBVSH)

Referral Request (Surrey)

10436 173rd Street, Surrey, BC, V4N 5H3 Phone: 604-514-8383 | FAX: 604-427-2494 | bbvsh.com | info@bbvsh.com
Refer to:*

Critical Care*SurgeryOncologyNeurologyInternal MedicineCardiologyEmergencyPhysiotherapyDentistryBehaviour
* If you selected "Critical Care": This is a specific referral to a board-certified critical care specialist. If it is after hours, there will be a call in fee.
Type of referral*

Direct Transfer****UrgentNext Available
If sending patient immediately, time of arrival:
Expected time of arrival
**** Please call 604-514-8383 when sending direct transfers.
List any contraindications to sedation/anesthesia and/or adverse reactions to particular drugs:
Abdominal Ultrasound only - no proceduresAbdominal Ultrasound with procedures (aspirates, biopsies or centesis)Thoracic Cavity and Mediastinum only - no procedures; this is NOT for echocardiogramsThoracic Cavity and Mediastinum with procedures (aspirates, biopsies or centesis); this is NOT for echocardiogramsOther area (eyes, shoulder, etc) requested. Please indicate below:
Indicate "other area":
Note: We do not do partial abdominal ultrasounds. If you wish to have an ultrasound performed on any part of the abdomen, please check box for abdominal ultrasound or abdominal ultrasound with procedures.
Referring Veterinarian
Referring Veterinarian
Referring Hospital*
Daytime Phone Number*
Format: (000) 000-0000.
After Hours Phone Number
Format: (000) 000-0000.
FAX Number
Format: (000) 000-0000.
Clinic Email Address
Preferred Method of Contact

PhoneFaxEmail
Client Information
Client Name*

First NameLast Name
Client Primary Phone*
Format: (000) 000-0000.
Method of Primary Phone

Cell PhoneLandline
Client Secondary Phone
Format: (000) 000-0000.
Method of Secondary Phone

Cell PhoneLandline
Client Email Address
Client Street Address
Client City
Client Postal Code*
Patient Information
Patient Name*
Species*
Breed
Weight
Kilograms
Fur Colour*
Patient Sex

FMFSMN
Birthdate*

MonthDayYear
Date
Reason For Referral
Current Concern(s) Requiring Referral*
eg. clinical history, PE findings, etc
Diagnostic Tests performed*
eg. lab reports, etc
Current Medications currently or previously given*
If the service to which you have referred this case feels that your patient could benefit from an internal referral, can this occur without contacting you?*

YesNo
Relevant Medical Records arriving by*

File Upload (see below)FaxEmailSent with Owner
Click Add files below to upload any supporting document or Radiographs.*

Please upload the patient's medical records. Records must be submitted immediately to prevent delays for the client. Please submit zipped high resolution Radiographs. 20MB max file size per file.
Cancelof
Please Note

Please send all relevant records, lab results and diagnostic images. Once you have sent your referral, please contact our office to confirm receipt.

Phone: 604-514-8383 Fax: 604-427-2494
Should be Empty:

Referral Request (Surrey)

Referring Veterinarian

Client Information

Patient Information

Reason For Referral