Referring Vets - Capital City Vet

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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 to your patients.

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'.

REFERRAL DETAILS

Is this an urgent Referral?

Yes

Reason for Referral or Primary Complaint

I would prefer to schedule a:

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

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

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*

MM slash DD slash YYYY

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

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'.

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

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*

MM slash DD slash YYYY

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

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'.

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

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*

MM slash DD slash YYYY

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

Dermatology Referral Form

"*" indicates required fields

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

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

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*

MM slash DD slash YYYY

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

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'.

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

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*

MM slash DD slash YYYY

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

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'.

REFERRAL DETAILS

Is this an urgent Referral?

Yes

Reason for Referral or Primary Complaint

Specific expectations or requests for this 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

Complete Blood Count (CBC)

Histology or Cytology

Biochemistry

Urinalysis

Thoracic Radiographs

Abdominal Ultrasound

Other Tests

Please specify which tests

Is the patient currently on an NSAID?

Yes

If the patient is on an NSAID, is the use intermittent

Yes

N/A

Is the patient currently on steroids?

Yes

N/A

If the patient is taking steroids, is the use intermittent?

Yes

N/A

Other Current Medications

Pertinent History (including vaccination status) and Tentative Diagnosis

Max. 5000 Characters

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

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*

MM slash DD slash YYYY

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

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'.

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

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*

MM slash DD slash YYYY

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

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'.

REFERRAL DETAILS

Is this an urgent Referral?

Yes

Reason for Referral or Primary Complaint

I would prefer to schedule a:

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

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

Additional Comments

Max. 5000 Characters

REFERRING VETERINARIAN INFORMATION

Hospital Name*

Hospital Phone Number

Referring Veterinarian’s Name*

Fax Number, if applicable

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*

MM slash DD slash YYYY

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

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

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'.

REFERRAL DETAILS

Is this an urgent Referral?

Yes

Primary Complaint*

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

CT Scan

Ultrasound

Radiographs

Scope

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

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*

MM slash DD slash YYYY

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

<img src="https://www.capcityvet.com/wp-content/uploads/2023/02/LOGO-CapitalCity-inline.png" alt="logo"/>

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