Referral Form – Beattie Pet Hospital

Clinic Information

Date

Name of Clinic

Referring Veterinarian

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Veterinarian Email

In order to set up a consultation, please send complete Medical History and appropriate diagnostics (blood work, radiographs or any radiograph reports) to [email protected] or use the file upload section below. If you have any questions please call us at 289-639-5600.

Schedule referral surgery via rDVM
Surgical Referral Services to contact client directly for scheduling.

Please note that a 20% deposit will be required to confirm surgery booking

Medical History

Drop files here or

Owner Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Pet Information

Name

First

Species

Breed

Coat Color

Age

Sex

Weight

Has this pet ever needed sedation for handling due to behavior concerns?*

Yes
No

Presenting Problem:

Please indicate the presenting problem (ie. surgical referral, post op care, etc)

Condition of Patient:

Healthy
Stable
Critical

Is this referral for:

Continuation of care
Treatment/surgery and return to rDVM

History

Please give a complete medical history of the presenting complaint, bullet points are appreciated

Radiographs sent
Bloodwork sent
Other diagnostics sent

Current Medications

Please all medications currently prescribed for current and recurring conditions