Emergency Referral Request Form – OVC Health Sciences Centre

I have communicated with OVC who has confirmed that they will accept my patient. I confirm receipt of OVC's initial estimate based on the information I have provided.*
- Yes
- No
Upload signed Referral Intake form*
My clients estimated time of arrival to OVC HSC is*

: HH

MM
Referring Veterinarian Information*
Referring Veterinarian Clinic name Clinic phone number Clinic email
Owner's Information*
Owner's name Owner's email Owner's phone number
Owner's address*
Street Address Unit # City Province Postal Code
Patient Information*
Patient Name Breed - If mixed breed, please enter dominant breed(s) Colour Sex Patient Weight in kgs
Age (month or year)*
Reason for emergency referral*
Pertinent history and findings*
Current medication(s), dose and time of last administration*
If you are uploading your treatment sheet, please enter "see attachment" in the text box above.
Upload treatment sheet
Is this the patient's first visit to your clinic?*
- Yes
- No
Radiology (jpeg images and/or report)
Radiographs, US, CT, MRI
Copy/paste PACs share link/URL (please note that some URLs are too long for the field and therefore a URL shortener is required https://tinyurl.com)
Lab results (blood, urinalysis, cytology, histology)
Pertinent medical records (within the last 2 years)
Drop files here or