Patient Referral Form

Referral Instructions: When referring your patient to Princess Animal Hospital, please complete this online submission form. All pertinent medical records can be uploaded through this form or submitted via email to urgentcare@princessanimalhospital.com.

REFERRING VETERINARIAN INFORMATION

Name of referring hospital *

Name of Referring Veterinarian *

Phone Number *

Fax Number

Cell Number *

Email Address of Referring Veterinarian *

Please indicate which number is your preferred method of contact

Does your client know that you are sending this referral? *

Yes
No

Patient's Name *

Date of Birth

Breed *

Colour

Gender

Weight

Patient is *

Critical
Stable
Healthy

Referral Reason *

Please note we do not have daytime urgent care and therefore the patient will be returned to your hospital in the morning. *

I understand

CURRENT MEDICATIONS (Include medications, doses, fluids, rate, and last time administered.)
(maximum 4000 characters)

I am sending medications with pet *

Yes
No

MEDICAL HISTORY (Medical records, lab results, additional sheets, can be uploaded below.)
(maximum 4000 characters)

Lab Samples *

Coming with the client
Not collected yet
Completed and attached

X-Rays

Coming with the client
Not performed yet
X-rays attached to this submission form

Upload Files Here

Checklist

Medical records are attached to this submission form.
Client is aware of exam fee and that a treatment plan will be reviewed at admission.
PAH has been called and notified of estimated time of arrival.
Client has been informed that if the animal is stable and PAH has another critical patient, there may be a wait.

Thank you for taking the time to complete this form. A member of our team will be in touch if we have questions or require further information.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Patient Referral Form

Which practice would you like to register with?

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

DOCUMENTS