Referral Form - Online

WVSC Online Referral Form

Is this a Referral to Emergency Service?

Referral Department (please check all that apply, must check at least 1)
Cardiology: Etienne Cote (Diplomate ACVIM (Cardiology))
Critical Care: Val Madden (Diplomate ACVECC), Jenefer Stillion (Diplomate ACVECC)
Ophthalmology: Kelli Combs Ramey (Diplomate ACVO)
Internal Medicine: Debra Henderson (Diplomate ACVIM), Chantal McMillan (Diplomate ACVIM)
Oncology: Glenna Mauldin (Diplomate ACVIM), Neal Mauldin (Diplomate ACVIM and Diplomate ACVR)
Rehabilitation: Caroline Dahlen (DVM, Certified in Canine Rehabilitation Therapy)
Radiology: Nic Rousset (Diplomate ECVDI)
Surgery: Terri Schiller (Diplomate ACVS), Bronwyn Fullagar (Diplomate ACVS), Tamara MacDonald (Diplomate ACVS)
Anesthesiology: Matt Read (Diplomate ACVA)

Client Name (Full) (required)

Client Phone (required)

Patient Name (required)

Patient Breed (required)

Patient’s Sex (required)
Neutered Male
Spayed Female

Patient Weight (kg) (required)

Patient Age (required)

Referring Hospital Name (required)

Referring Veterinarian Name (required)

Referring Veterinarian Phone (required)

Referring Veterinarian Fax

Referring Veterinarian Email (required, a copy of this form will be emailed here for your records)

Other Veterinarians involved in this case

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

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

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

History and Physical Findings

Laboratory / Radiographic / Biopsy Information

Has the client been given an estimated fee for services?

If a quote was given, how much was quoted?

Outpatient Radiology (please incl history and other info in space above):
Ultrasound  Cystocentesis  Consent for Sedation (CBC/Chem within 2 wks)
                         FNA (normal platelet count within 1 week)
Radiographic Interpretation (please email DICOM images to )
CT (Please enter study requested below (requires CBC, chem, UA & PE within 2 wks))

If you cannot be reached and there is a concern regarding the stability of the patient, may we transfer to appropriate specialist for treatment if we deem the situation needs to be dealt with on an emergent basis?