Surgery Referral Form

Referral Instructions: When referring your patient to Campbell River Veterinary Hospital, please complete this online submission form. All pertinent medical records can be uploaded through this form or submitted via email to info@campbellrivervet.com.

Please note that a $500 dollar booking fee is required for all referral surgeries. It is refundable up until 48 hours before your appointment date.

REFERRING VETERINARIAN INFORMATION

Name of referring hospital *

Name of Referring Veterinarian *

Phone Number *

Fax Number *

Email Address of Referring Veterinarian *

CLIENT INFORMATION

Owner's Full Name *

Co-Owner's Name

Address *

City *

Province *

Postal Code *

Phone Number *

Email Address *

PATIENT INFORMATION

Pet's Name *

Breed *

Age *

Colour *

Weight *

Gender *

Presenting Complaint/Diagnoses: *

History:

Current Medications/Dosages:

DOCUMENTS

Test results and all pertinent medical records can be uploaded through this form or sent via email to info@campbellrivervet.com.

Upload Files Here

Your documents will be sent by *

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Email

We are happy to answer any questions you may have. Thank you for entrusting us with the care of your pet.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Surgery Referral Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

DOCUMENTS

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