Internal Medicine 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 internalmedicine@capcityvet.com.

Get Started

Is this an urgent referral? *

Reason for referral *

Referring Veterinary Practice *

Referring Veterinarians Name *

Client Name *

First

Last

Client Email *

Client Primary Phone Number *

Client's Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient Name *

Species *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

DOB *

If your patient receives fear free medications (i.e. Gabapentin and/or Trazodone) prior to veterinary visits, we do recommend they receive the medication prior to the consultation. If they require a refill, you will have to dispense the medication.

Please upload any medical records and relevant diagnostics: *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please ensure all client information is accurate, as this will allow our team to contact the client without delay.

Referring Veterinarians

Emergency Services

Internal Medicine Referral Form

Veterinary Services

Contact Details