Is this a Referral to
Emergency Service?
www.westernvet.ca

1802 - 10th Ave S.W. Calgary, AB T3C 0J8
Phone: (403) 770-1340 Toll Free: 1-866-770-1340
Fax: (403)770-1344
referral@westernvet.ca
(If yes, please check)
 Critical Care
 Jenefer Stillion
Patient Referral Form
Today’s Date: ___________________
(also available online at www.westernvet.ca)
DVM
Diplomate American College of
Veterinary Emergency & Critical
Care
 Cardiology

Etienne Cote
 DVM
 Ophthalmology
 Kelli Ramey
DVM

 Internal Medicine
Diplomate American College of
Veterinary Internal Medicine
(Cardiology)
Diplomate American College of
Veterinary Ophthalmology

Kevin Cosford
BSc. DVM
Diplomate American College of
Veterinary Internal Medicine
 Debra Henderson
Chantal McMillan
BSc. DVM
Diplomate American College of
Veterinary Internal Medicine
 DVM

Oncology
 Glenna Mauldin
Diplomate American College of
Veterinary Internal Medicine
DVM, MS

Diplomate American College of
Veterinary Internal Medicine
(Oncology)
 Neal Mauldin
DVM


 Rehabilitation

Caroline Dahlen
Certified in Canine
 DVM,
Rehabilitation Therapy
 Surgery
Russell Fugazzi
 DVM
 Aylin Atilla
 DVM
 Terri Schiller
 DVM
 Radiology
Rousset
 Nic
DVM

 Anesthesiology
Daniel Pang
 BVSc, PhD
Diplomate American College of
Veterinary Internal Medicine
(Oncology)
Diplomate American College of
Veterinary Radiology (Radiation
Oncology)
Diplomate American College of
Veterinary Surgeons
Diplomate American College of
Veterinary Surgeons
Diplomate American College of
Veterinary Surgeons
Diplomate European College of
Veterinary Diagnostic Imaging

Diplomate American College of
Veterinary Anesthesiologists
Diplomate European College
Veterinary Anesthesia & Analgesia
Matt Read
DVM, MVetSc
Diplomate American College of
Veterinary Anesthesiologists
Owner Information:
Primary Phone:
(
Client Name:
)
Patient Information:
Sex:
F
FS
M
Additional:
Patient Name:
MN
(
)
Breed:
Date of Birth:
Referring Veterinarian Information:
mm / dd / yyyy
kg
Weight:
Hospital Name:
Veterinarian:
Phone:
Fax:
Email:
Other veterinarians involved in this case:
Please indicate how you are sending the following:
Referral Form
Relevant Medical Records
Lab Results
Radiographs
E-mail or Online
Fax
With Client
Courier

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
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History and Physical Finding: _________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Laboratory / Radiographic / Biopsy Information: _________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Has the client been given an estimated fee for services?
YES
NO
If so, how much was quoted? ___________________________________________________________
Outpatient Radiology (please incl history and other info in space above)
 Ultrasound
 Cystocentesis
 Consent for sedation
 FNA (normal platelet count within 1 week)
 CT Study Requested ________________________ (requires CBC, chem, UA & PE within 2 wks)
 Radiographic Interpretation (please email DICOM images to referral@westernvet.ca)
If you cannot be reached and there is a concern regarding the stability of the patient, may we transfer to
appropriate specialist for treatment if we deem the situation needs to be dealt with on an emergent basis?
YES
NO
(please circle one)