+1 778 484 5777
[email protected]
1949 Harvey Ave, Kelowna BC
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Please note that we are currently accepting patients by appointment only
Referral Form
Referring Veterinarian Information
Referring Veterinarian
(Required)
First
Last
Referring Veterinary Clinic
(Required)
Referring Veterinary Email
(Required)
Referring Veterinary Phone
(Required)
Referring Veterinary Fax
Client Information
Client Name
(Required)
First
Last
Client Email
(Required)
Client Phone
(Required)
Client Address
(Required)
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Patient Information
Pet Name
(Required)
Species
(Required)
Canine
Feline
Breed
(Required)
Color
(Required)
Sex
(Required)
Female
Male
Female - Spayed
Male - Neutered
DOB
(Required)
Behavior/Temperament
(Required)
Weight (lbs)
(Required)
Status
(Required)
Non Urgent
Urgent
Emergency
Limb(s)
RF
LF
RH
LH
Not Applicable
Additional Information
Reason for Referral
(Required)
Please include presenting complaints, previous and current medical therapies and duration of problem.
Bloodwork Done?
(Required)
Yes
No
Radiographs? (Please Attach)
(Required)
Yes
No
Upload Documents:
(Required)
Please upload x-rays as JPEG files (no DICOM or other formats).
Drop files here or
Select files
Accepted file types: jpg, jpeg, Max. file size: 1 MB.
Current Treatment and Medications (including any preventatives)
Previous Medical History and Vaccination History
Additional Comments
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