Laparascopy/Endoscopy Referral Form

When referring your patient to our hospital, please complete this form and upload all pertinent medical records.

REFERRING VETERINARIAN INFORMATION

Hospital Name *

Clinic/Hospital Phone Number *

Clinic/Hospital Fax Number *

Clinic/Hospital Email *

Name of Referring Veterinarian *

CLIENT INFORMATION

Full Name *

Name of secondary contact and/or spouse

Address *

City *

Province *

Postal Code *

Phone Number*

Email Address *

PATIENT INFORMATION

Patient's Name *

Birth Date *

Approximate

Age *

In months/years, or birthdate

Species *

Breed *

Colour / Markings *

Sex *

Weight *

In kg

REQUIRED DOCUMENTATION / INFORMATION

Service requested *

Laparoscopy
Endoscopy

Tentative Diagnosis: *

Present Complaint:*

Required documentation:

Pre-Anesthetic Bloodwork (Chem 15/CBC/Lytes)
Complete medical records
Radiographs

Please note that we have started performing bloodwork on the morning of surgery for many of our procedures. Bloodwork done ahead of time at the regular clinic will be reviewed by the surgeon and is still recommended to rule out other comorbidities.

Upload Required Documentation: *

Additional information may be required depending on the services selected.

Additional Information / Comments:

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Laparascopy/Endoscopy Referral Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

REQUIRED DOCUMENTATION / INFORMATION

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