Referral Form

We unfortunately do not accept faxed referrals reliably.

Please submit referrals online through this form or by email at referrals@wavesvet.com.

If the referral form is not filled out properly or is incomplete, we cannot process it. Please make sure you are putting all of the information in or you will receive an email asking for it to be redone. Thank you.

Date *

Today

REFERRING HOSPITAL INFORMATION

Name of Referring Hospital *

Name of Referring Veterinarian *

Phone Number *

Fax Number *

Email Address of Referring Veterinarian *

Preferred Method of Communication *

REFERRAL DEPARTMENT

Department Referring To *

Patient Should Be Seen: *

If the service to which you have referred this case feels that your patient could benefit from an internal referral, can this occur without contacting you? *

Has an estimate been provided to the client? (If yes, please email a copy to us)

CLIENT INFORMATION

Client's Full Name *

Client's Phone Number *

Client's Address *

City *

Province *

Postal Code *

Email Address *

PATIENT INFORMATION

Pet's Name *

DOB *

Species *

Breed *

Colour *

Gender *

Weight *

Behaviour / Temperament *

ex: nervous, aggressive, calm, etc.

Presenting Complaint *

Previous Medical History *

Medication *

Please include the name of medications, dosage, and frequency of doses.

Labs/Diagnostics *

RELEVANT DOCUMENTS

Please include patient history, any medical findings, images or other files. ALL files should be sent to referrals@wavesvet.com.

Documents will be sent via: *

ACKNOWLEDGEMENT & CONSENT

I acknowlege that I MUST include all diagnostics and lab work with a brief summary. If the referral form is incomplete, you will receive a request to resubmit the form. *

YES, I have included all diagnostics and lab work

I consent to the use and storage of my information in accordance with the terms and conditions detailed in the WAVES Privacy Policy (linked below) *

I agree to the terms and conditions

Please verify that you are human *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Referral Form

REFERRING HOSPITAL INFORMATION

REFERRAL DEPARTMENT

CLIENT INFORMATION

PATIENT INFORMATION

RELEVANT DOCUMENTS

ACKNOWLEDGEMENT & CONSENT

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