Ophthalmology 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. 

Please Note: There seems to be a problem submitting the form when using Internet Explorer (IE) so please use another browser until the issue has been addressed.

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
Hospital name
Email address
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 (01 Jan 2014)
Date of initial presentation for problem
(01 Jan 2014)
Patient history/findings
Current medications given for ocular condition (name/dosage/frequency)
Previous medications for ocular condition (include name, dosage, frequency, date and response)
Non-ocular medical conditions (for example, diabetes or heart disease)
Current medications for patient's non-ocular conditions
Other medical conditions or medications/therapy
Special concerns and/or considerations