Rehabilitation Referral Form

The following referral form is for rehabilitation, acupuncture and laser therapy services. 

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 online referral form when using Internet Explorer (IE). Pease 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
Patient name
Species
Breed
If the patient is a dog, is the animal a working dog or canine athlete? Yes
No
If you answered yes to the above question, please give more details.
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
Previous surgeries
Were previous diagnostic tests performed?
Laboratory Reports
If you are having difficulties attaching test document files through the online system below, please email the documents to vmccorrespond@usask.ca. In the subject line of your email, please include the animal's first and last name.
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