Instinct Shareville
Service Portal

Shareville is our online portal allowing you to access your patient’s latest records with us and keep up to date on their progress.

View your Patients Guide to the Shareville Portal (Coming Soon)

Refer a Patient

Our referral portal is the fastest way to request an appointment with one of our specialists and helps to ensure they receive all the information they require to provide the best possible care for your patients.

Internal Medicine
Cardiology
Dentistry
Dermatology
Emergency &  Critical Care
Medical Oncology
Ophthalmology
Surgery
Outpatient Imaging

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 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?

Yes

Reason for Referral or Primary Complaint

Specific expectations or requests for this referral*

Pertinent history, including physical exam findings and abnormal test results*

Max 5,000 Characters

Tentative Diagnosis

Current Medications*

Please list any anesthetic concerns*

Please check any current or previous comorbidities and provide a brief description of these conditions:*

Allergies ± atopic dermatitis

Upper airway disease

Lower airway disease

Cardiac disease

Liver disease

Kidney disease

Endocrine disease

Other

Description of Comorbidity

Bloodwork Completed

Yes

Radiographs Taken

Yes

Aspirates/Biopsy Taken

Yes

Date

Month

Day

Year

Date

Month

Day

Year

Date

Month

Day

Year

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Body Condition Score (1 – 9)*

Rabies Vaccination Current

Yes

Temperament

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

Infectious

Yes

Painful

Yes

Muzzle*

Yes

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.

Labs Results

Max. file size: 50 MB.

Diagnostic Images

Max. file size: 50 MB.

Cytology Results

Max. file size: 50 MB.

Histopathology Results

Max. file size: 50 MB.

Other Results or Reports

Max. file size: 50 MB.

Description*

Max. 5000 Characters

CAPTCHA

Cardiology 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?

Yes

Reason for Referral or Primary Complaint

Specific expectations or requests for this referral

Pertinent History (including vaccination status) and Tentative Diagnosis

Max. 5000 Characters

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

Complete Blood Count (CBC)

Histology or Cytology

Biochemistry

Urinalysis

Thoracic Radiographs

Abdominal Ultrasound

Other Tests

Please specify which tests

Flea & Tick preventatives used in the past year*

If Other, please specify

Current Medications other than those listed above

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Rabies Vaccination Current

Yes

Temperament*

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

If FAS 2 or greater, Gabapentin or Trazodone MUST BE PRESCRIBED in order for the echocardiogram to be performed.*

Gabapentin or trazodone prescribed

Not applicable, FAS <2

Infectious

Yes

Painful

Yes

Muzzle*

Yes

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.

Description*

Max. 5000 Characters

CAPTCHA

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?

Yes

Reason for Referral or Primary Complaint

Specific expectations or requests for this referral

Pertinent History (including vaccination status) and Tentative Diagnosis

Max. 5000 Characters

Current Medications

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Rabies Vaccination Current

Yes

Temperament*

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

Infectious

Yes

Painful

Yes

Muzzle*

Yes

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.

Description*

Max. 5000 Characters

CAPTCHA

Dermatology 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?

Yes

Reason for Referral or Primary Complaint*

Age of Onset*

Seasonality*

If signs are seasonal, or partially seasonal, when are they worse?

Flea & Tick preventatives used in the past year*

If Other, please specify

Has a Diet Trial been performed (please include the name of diet used and approximate duration of trial)?

Are other people or pets in the household affected?

Yes

Have there been any adverse reactions to medications in the past (please write ‘none’ or ‘N/A’ if this does not apply), and if so, which medications*

Current Medications*(please write ‘none’ or ‘N/A’ if no current medications)*

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Rabies Vaccination Current

Yes

Infectious

Yes

Fractious

Yes

Painful

Yes

FILES

Please be sure to separately attach copies of any relevant lab work performed by outside labs that may not otherwise be included in the Medical Record (eg biopsies, cultures).

The following files are attached:

Medical Records

Max. file size: 50 MB.

Biopsy Results

Max. file size: 50 MB.

Culture Results

Max. file size: 50 MB.

Other Reports

Max. file size: 50 MB.

Description*

Max. 5000 Characters

CAPTCHA

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?

Yes

Reason for Referral or Primary Complaint

Specific expectations or requests for this referral

Pertinent History (including vaccination status) and Tentative Diagnosis

Max. 5000 Characters

Current Medications

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Rabies Vaccination Current

Yes

Temperament*

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

Infectious

Yes

Painful

Yes

Muzzle*

Yes

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.

Description*

Max. 5000 Characters

CAPTCHA

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?

Yes

Reason for referral - Please select from the dropdown menu

Client expectations

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

Complete Blood Count (CBC)

Histology or Cytology

Biochemistry

Urinalysis

Thoracic Radiographs

Abdominal Ultrasound

Other Tests

Current medications (please note any recent or chronic NSAID or steroid use)

Pertinent History or Short Case Summary

Max. 5000 Characters

Tentative diagnosis

Please note any comorbidities

Max. 5000 Characters

Up to date on vaccinations?

Yes

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Rabies Vaccination Current

Yes

Temperament*

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

Infectious

Yes

Painful

Yes

Muzzle*

Yes

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.

Description*

Max. 5000 Characters

CAPTCHA

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?

Yes

Reason for Referral or Primary Complaint*

Specific expectations or requests for this referral*

Does the patient have a history of eye issues? Please describe*

Describe any other ongoing health issues

Current Medications

Pertinent History (including vaccination status) and Tentative Diagnosis

Max 5,000 Characters

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Rabies Vaccination Current

Yes

Temperament*

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

Infectious

Yes

Painful

Yes

Muzzle*

Yes

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.

Labs Results

Max. file size: 50 MB.

Diagnostic Images

Max. file size: 50 MB.

Other Reports

Max. file size: 50 MB.

Description*

Max. 5000 Characters

CAPTCHA

Surgery 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?

Yes

Reason for Referral or Primary Complaint

Specific expectations or requests for this referral*

Pertinent history, including physical exam findings and abnormal test results*

Max 5,000 Characters

Tentative Diagnosis

Current Medications*

Please list any anesthetic concerns*

Please check any current or previous comorbidities and provide a brief description of these conditions:*

Allergies ± atopic dermatitis

Upper airway disease

Lower airway disease

Cardiac disease

Liver disease

Kidney disease

Endocrine disease

Other

Description of Comorbidity

Bloodwork Completed

Yes

Radiographs Taken

Yes

Aspirates/Biopsy Taken

Yes

Date

Month

Day

Year

Date

Month

Day

Year

Date

Month

Day

Year

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Body Condition Score (1 – 9)*

Rabies Vaccination Current

Yes

Temperament

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

Infectious

Yes

Painful

Yes

Muzzle*

Yes

FILES

Please include all documents, including medical records, laboratory and imaging reports, and radiographs, for a minimum of the past 2 years.

The following files are attached:

Medical Records

Accepted file types: dcm, gif, jpg, pdf, png, Max. file size: 50 MB.

Labs Results

Max. file size: 50 MB.

Diagnostic Images

Max. file size: 50 MB.

Cytology Results

Max. file size: 50 MB.

Histopathology Results

Max. file size: 50 MB.

Other Results or Reports

Max. file size: 50 MB.

Description*

Max. 5000 Characters

CAPTCHA

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?

Yes

Primary Complaint*

Imaging Requested (specify areas of concern or to image below)

CT Scan

Radiographs

Specific areas to image or other requests for this referral*

Do you want a follow up consultation with a specialty service at Capital City?

Yes

Specialty Department

Pertinent History and Tentative Diagnosis

Max 5,000 Characters

Current Medications

History of anesthetic complications, if any

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

Name of Family Animal Hospital, if different to above*

Referral Submitted By

Email Address*

CLIENT INFORMATION

First Name*

First

Alternate Contact First Name

Last Name*

Last

Alternate Contact Last Name

Address*

Street Address Address Line 2 City Province Postal Code

Email Address*

Home Phone*

Mobile Phone

Work Phone

PATIENT INFORMATION

Name*

Breed*

Species*

Sex*

Color / Description

DOB*

Month

Day

Year

Weight (in kg)*

Rabies Vaccination Current

Yes

Temperament*

Friendly and relaxed (FAS 0)

Excited ± mild anxiety (FAS 1)

Moderate anxiety (FAS 2-3)

Marked anxiety (FAS 4)

Aggressive (FAS 5)

Dog Aggressive Only

Infectious

Yes

Painful

Yes

Muzzle*

Yes

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.

Labs Results

Max. file size: 50 MB.

Diagnostic Images

Max. file size: 50 MB.

Other Reports

Max. file size: 50 MB.

Description*

Max. 5000 Characters

CAPTCHA

Instinct Shareville Service Portal

Refer a Patient

Internal Medicine Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Cardiology Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Dentistry Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Dermatology Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Emergency Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Oncology Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Ophthalmology Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Surgery Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Outpatient Imaging Referral Form

REFERRAL DETAILS

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

FILES

Instinct Shareville
Service Portal