Referral Form - Online

WVSC Online Referral Form





Is this a Referral to Emergency Service?
Yes No 

Referral Department (please check all that apply)
 Cardiology: Etienne Cote (Diplomate ACVIM (Cardiology))
 Ophthalmology: Kelli Combs Ramey (ACVO Diplomate)
 Internal Medicine: Kevin Cosford (Diplomate ACVIM), Debra Henderson (Diplomate ACVIM), Chantal McMillan (Diplomate ACVIM)
 Oncology: Glenna Mauldin (Diplomate ACVIM), Neal Mauldin (Diplomate ACVIM and Diplomate ACVR)
 Rehabilitation: Caroline Dahlen (DVM)
 Surgery: Audrey Remedios (Diplomate ACVS), Terri Schiller (Diplomate ACVS), Russell Fugazzi (Diplomate ACVS)
 Anesthesiology: Matt Read (Diplomate ACVA), Daniel Pang (Diplomate ACVA and Diplomate ECVAA)

Client Name (Full) (required)

Client Phone (required)

Patient Name (required)

Patient Breed (required)

Patient’s Sex
 Male
 Neutered Male
 Female
 Spayed Female

Patient Weight (kg)

Patient Age

Referring Hospital Name

Referring Veterinarian Name

Referring Veterinarian Phone

Referring Veterinarian Fax

Referring Veterinarian Email

Other Veterinarians involved in this case

Relevant Medical Records will be sent via:
 Email or Online (referral@westernvet.ca)
 With Client
 Fax (403-770-1344)
 Courier Service

Lab Results will be sent via:
 Email or Online (referral@westernvet.ca)
 With Client
 Fax (403-770-1344)
 Courier Service

Radiographs will be sent via:
 Email or Online (referral@westernvet.ca)
 With Client
 Fax (403-770-1344)
 Courier Service

History and Physical Findings

Laboratory / Radiographic / Biopsy Information