Forms

Veterinarian Referral Form

Download Veterinarian Referral form in PDF format

Fax form to (604) 279-2040

or fill out online version below

*Indicates mandatory field

Date

PATIENT INFORMATION

Owner Name*

Phone*

Email*

Home Phone*

Cell or Pager*

Pet’s Name

Age*

Sex*

REFERRING HOSPITAL

Hospital Name*

Dr. Name*

Phone*

Fax*

E-Mail*

Records and Lab reports can be faxed to 604-279-2040

Case History

Diagnostic Performed (please attach any laboratory and/or other diagnostic reports)

Treatment/Medications (Dosages & Durations)

Thank you for entrusting the Animal Dermatology Clinic of BC with your dermatology specialty needs. We will be sending you a typed report, this will include a diagnosis, the tests that were performed and a recommended course of action.

Richmond
140-8040 Garden City Rd
Richmond, BC
604-270-6199

Langley
306-6325 204th St
Langley, BC
604-270-6199

*PLEASE HAVE YOUR CLIENT CALL US TO SET UP AN APPOINTMENT*

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Veterinarian Referral Form

PATIENT INFORMATION

REFERRING HOSPITAL

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Veterinarian Referral Form

PATIENT INFORMATION

REFERRING HOSPITAL