Dentistry Referral Form

*Indicates required fields

Please contact Capital City Specialty & Emergency Animal Hospital at (613) 244-7387 if you need assistance with any referral.

If the attachments surpass the maximum 50MB file size, please email the patient’s records and imaging directly to dentistry@capcityvet.com.

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REFERRAL DETAILS

Is this an urgent referral?

Reason for Referral or Primary Complaint

Pertinent History (including vaccination status) and Tentative Diagnosis

Max. 5000 Characters

Current Medications

Additional Comments

0 of 5000 max characters

REFERRING VETERINARIAN INFORMATION

Veterinary Practice *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Referring Veterinarian’s Name *

Name of Family Animal Hospital, if different to above *

Referral Submitted By

CLIENT INFORMATION

Name *

First

Last

Alternate Contact Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email Address *

Home Phone *

Mobile Phone

Work Phone

PATIENT INFORMATION

Name *

Species *

Color / Description

Rabies Vaccination Current

Breed *

Sex

DOB *

Weight (in kg) *

Infectious

Painful

Muzzle *

FILES

Please include all documents which are relevant to the presenting complaint here.

The following files are attached:

Medical Records

Max. file size: 50 MB.

Lab Results

Max. file size: 50 MB.

Diagnostic Images

Max. file size: 50 MB.

Other Reports

Max. file size: 50 MB.

Please make sure your file name does not include any special characters ($&^* etc.) as this can corrupt the file submission.

Description *

Referring Veterinarians

Emergency Services

Dentistry Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Veterinary Services

Contact Details