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Surgery 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)
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
Relevant Patient History
Exam Findings
Does the patient have an active infection?
Yes
No
Please clarify
Has the patient ever had MRSA/MRSP?
Yes
No
Is the patient lame?
Please Select
Not Lame
Mild
Moderate
Severe
Diagnostic Test Results
Current Medications
Patient Cautions
Does the patient have behavioural concerns that require chemical sedation before vet visits
Yes
No
Aggression
Anxiety
Fear
Document Upload
Please include all pertinent medical records and diagnostic test results from the last 6 months. If the total size of your uploads exceeds 25MB, please send them to our email
surgery@petzoicvet.com
Documents sent via email
Medical Records
Diagnostic Images (Please submit JPEG X-rays)
Lab Results
Upload Documents
REFERRING VET DETAILS
Referring Veterinarian's Name
Practice Name
Phone
Email
Has the patient been seen or referred by another veterinary care provider before this referral?
No
Yes
Name of other veterinary care provider
Communications
Has a verbal estimate been provided to the client?
Yes
No
What was the range?
If our veterinarians identify additional treatments that could benefit your patient, do we have your permission to proceed before contacting you?
Yes
No
Submit
