emergency & referral services referral...
TRANSCRIPT
Emergency & Referral Services
ETERINARY EmergencyHospital
Mississauga Oakville.
Please return referral request to [email protected] or fax to 905-829-9646
www.vetemergency.ca 2285 Bristol Circle, Oakville, Ontario L6H 6P8 Tel: 905-829-9444 Fax: 905-829-9646
REFERRAL REQUEST
Date of Appointment: ________________________________
Time of Appointment: ________________________________
Doctor: ________________________________________
RDVM:____________________________________________ Hospital: __________________________________________
Phone: ______________________________ Fax: __________________________ Email: ____________________________
Client: __________________________________________________ Phone: ________________________________________
Address: ________________________________________________________ City: __________________________________
Postal Code: __________________ Additional Phone #’s: ______________________________________________________
Patient: ______________________________________________ Breed: ____________________________________________
Age: ___________ Sex: ___________ Weight: ________________________
** Please completely fill in client /patient information so records can be entered ahead of time **
Summary of History and Physical Findings: (Please DO NOT fax the complete medical record)
Lab Tests: ________________________________________________________________________________________________
Radiographs: __________________________________________________________________________
* Please fax lab results with this form. Please send radiographs /scans and reports with patient *
Current Medications: Current Diet:
Tentative Diagnosis:
Special Requests / Comments: