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101-11501 Buffalo Run Blvd Tsuut’ina AB T3T 0E4
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403.453.9111
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Client Registration Form
Vet Referral Forms
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Referral Form
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
September 11, 2026
Appointment Urgency
Next Available
Urgent (next few days)
Emergency (same day)
Call our hospital at
(403) 453-9111
to speak to our vet about emergency cases before transferring the patient.
CLIENT DETAILS
Primary Client
First Name
Last Name
Email
Phone
Address
Postal Code
Alternate Client
Name
Phone
PATIENT DETAILS
Name
Sex
Please Select
Male
Male Neutered
Female
Female Spayed
Date of Birth
Species
Breed (if applicable)
Colour
Body Weight (kg)
Pet Insurance Coverage
Yes
No
Insurance Provider
Policy Number
Medical Summary
Reason for Referral
Please Select
Abdominal Ultrasound
CT
Emergency Transfer
HBOT
Surgery
Details
Sites To Be Imaged:
Whole Body
Head
Neck/C1-T2
T3-L7/S1
Pelvis/Tail
Thorax
Abdomen
Left:
Carpus/Foot
Elbow
Shoulder
Stifle
Tarsus/Foot
Right:
Carpus/Foot
Elbow
Shoulder
Stifle
Tarsus/Foot
Contrast?
Yes
No
Telemedicine Report Required?
Yes
No
Seizures?
Yes
No
Previous Trauma?
Yes
No
Chronic Respiratory Disease?
Yes
No
Relevant Patient History
Does the patient have behavioural concerns that require chemical sedation before vet visits?
Yes
No
Aggression
Anxiety
Fear
Exam Findings
Does the patient have an active infection?
Yes
No
Please clarify
Does the patient have an active skin infection?
Yes
No
Has the patient ever had MRSA/MRSP?
Yes
No
Is the Patient Lame?
Not Lame
Mild
Moderate
Severe
Diagnostic Test Results
Current Medications
Document Upload
Please include all pertinent medical records and diagnostic test results from the last 6 months.
Documents sent via email
Medical Records
Diagnostic Images (Please submit DICOM images)
Lab Results
Upload Documents
REFERRING VET DETAILS
Referring Veterinarian's Name
Practice Name
Phone
Email
Communications
Has a verbal estimate been provided to the client?
Yes
No
What was the range?
If our veterinarian identifies additional treatments that could benefit your patient, may we proceed before contacting you?
Yes
No
Submit
