Orchard Veterinary Care Referral Form
Patient Information
Patient Name
Patient Age
Patient Species / Breed
Patient Sex
Male
Female
Presenting Complaint- include duration of problem, progression, any treatments, and response to treatment.
Onset
Acute
Chronic
Client Information
Client Name
Client Phone Number
Client email
Referring Hospital Information
Referring DVM name
Referring hospital
Referring DVM email
REFERRAL DEPARTMENT
Orthopedic Surgery/Fracture Repair
Ultrasound Abdominal
Ultrasound Echocardiogram
Dentistry/ Oral Surgery
General Surgery
Internal Medicine
Exotics
Chiropractic
PBMT - Laser Therapy
Patient Should be seen
Next Available Appointment
Priority appontment (if available)
URGENT
Relevant Documents
Please include patient history, and medical findings, images
Documents Included
Medical Records
Blood Work Results
Radiographs
Other
** Please Submit selected records by email to pets@orchardvetcare.ca for this referral for fastest turnaround - add any additional comments below
Submit Referral
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