Referral Form - Online

WVSC Online Referral Form





Is this a Referral to Emergency Service?
Yes No 

Referral Department (please check all that apply, must check at least 1)
 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)
 Radiology: Nic Rousset (Diplomate ECVDI)
 Surgery: 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 (required)
 Male
 Neutered Male
 Female
 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)

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

Has the client been given an estimated fee for services?
 Yes
 No

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 referral@westernvet.ca )
 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?
 Yes
 No