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 attachment(s) surpass the maximum 50MB file size, please email the patient's records and imaging directly to [email protected]

REFERRAL DETAILS

Is this an urgent Referral?
Max. 5000 Characters
Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

First Name*
Last Name*
Address*

PATIENT INFORMATION

Sex*
DOB*
Rabies Vaccination Current
Temperament*
Infectious
Painful
Muzzle*

FILES

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

The following files are attached:

Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. 5000 Characters

Emergency 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 attachment(s) surpass the maximum 50MB file size, please email the patient's records and imaging directly to [email protected]

REFERRAL DETAILS

Is this an urgent Referral?
Max. 5000 Characters
Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

First Name*
Last Name*
Address*

PATIENT INFORMATION

Sex*
DOB*
Rabies Vaccination Current
Temperament*
Infectious
Painful
Muzzle*

FILES

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

The following files are attached:

Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. 5000 Characters

Oncology 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 attachment(s) surpass the maximum 50MB file size, please email the patient's records and imaging directly to [email protected]

REFERRAL DETAILS

Is this an urgent referral?
Please select if this diagnostic has recently been completed for this patient, and attach the results at the end of this form for any items that have been selected
Max. 5000 Characters
Max. 5000 Characters
Up to date on vaccinations?
Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

First Name*
Last Name*
Address*

PATIENT INFORMATION

Sex*
DOB*
Rabies Vaccination Current
Temperament*
Infectious
Painful
Muzzle*

FILES

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

The following files are attached:

Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. 5000 Characters

Ophthalmology 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 attachment(s) surpass the maximum 50MB file size, please email the patient's records and imaging directly to [email protected]

REFERRAL DETAILS

Is this an urgent Referral?
Max 5,000 Characters
Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

First Name*
Last Name*
Address*

PATIENT INFORMATION

Sex*
DOB*
Rabies Vaccination Current
Temperament*
Infectious
Painful
Muzzle*

FILES

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

The following files are attached:

Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. 5000 Characters

Outpatient Imaging 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 attachment(s) surpass the maximum 50MB file size, please email the patient's records and imaging directly to [email protected]

REFERRAL DETAILS

Is this an urgent Referral?
Imaging Requested (specify areas of concern or to image below)
Do you want a follow up consultation with a specialty service at Capital City?
Max 5,000 Characters
Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

First Name*
Last Name*
Address*

PATIENT INFORMATION

Sex*
DOB*
Rabies Vaccination Current
Temperament*
Infectious
Painful
Muzzle*

FILES

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

The following files are attached:

Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. file size: 50 MB.
Max. 5000 Characters