Medicine Referral Form

Please complete the online form and click the "Submit" button at the bottom of the page. You will receive a confirmation email message immediately after submitting your referral form. 

If you have any questions or problems completing this form, please contact vmccorrespond@usask.ca.
 
Fields marked with a red asterisk must be completed before submission.

Confirmation Email Address:?
Referring Veterinarian's Information
Name
Phone
Fax
Hospital name
Address
City/town
Province
Postal code
Client Information
Client name
Address
City/town
Province
Postal code
Preferred phone Cell
Home
Work
Preferred #
Alternate phone Cell
Home
Work
Alternate #
Client email
Patient Information
Service Small Animal
Large Animal
Patient name
Species
Breed
DOB
(01 Jan 2014)
Gender M
F
NM
NF
Weight (kg)
Colour
Date and type of last vaccination
Date of initial presentation for problem
(01 Jan 2014)
Patient history/findings
Current therapy/medications for condition
Previous therapy/medications for condition
Other medical conditions or medications/therapy
Laboratory Reports Lab reports attached
Please return lab reports
Lab report #1
Lab report #2
Lab report #3
Medical Images Medical images attached
Please return medical images
Medical image #1
Medical image #2
Medical image #3
Tentative diagnosis #1
Tentative diagnosis #2
Tentative diagnosis #3
Special concerns and/or considerations