
Is this a Referral to
Emergency Service?
Today’s Date: ___________________
(If yes, please check)
Appointment
www.westernvet.ca
Critical Care

J Jenefer Stillion
Diplomate American College of
Veterinary Emergency & Critical
Care

Ophthalmology

Kelli Ramey
 DVM
 Internal Medicine
 Kevin Cosford
 BSc. DVM
 Debra Henderson
Diplomate American College of
Veterinary Ophthalmology
Diplomate American College of
Veterinary Internal Medicine
Serge Chalhoub
BSc. DVM
Diplomate American College of
Veterinary Internal Medicine
(also available online at www.westernvet.ca)
Owner Information:
Primary Phone:
Sex:
F

Fax:

DVM, MVetSc

Diplomate American College of
Veterinary Internal Medicine
(Oncology)
Mauldin
 Neal
DVM


 David Espinosa
 DVM

Rehabilitation

Caroline Dahlen
Certified in Canine
 DVM,
Rehabilitation Therapy
 Surgery
Fugazzi
 Russell
DVM

Audrey Remedios
 DVM, MVetSc

Terri Schiller
 DVM

 Anesthesiology
Read
 Matt
DVM, MVetSc
Diplomate American College of
Veterinary Internal Medicine
(Oncology)
Diplomate American College of
Veterinary Radiology (Radiation
Oncology)
Resident in Medical Oncology
Board Eligible, American College of
Veterinary Surgeons
Diplomate American College of
Veterinary Surgeons
Diplomate American College of
Veterinary Surgeons
Daniel Pang
Diplomate American College of
Veterinary Anesthesiologists

)
FS
M
Additional:
Patient Name:
MN
(
)
Breed:
Date of Birth:
Referring Veterinarian Information:
Veterinarian:
Oncology
Glenna Mauldin
(
Client Name:
Patient Information:
 BSc. DVM
Diplomate American College of
Veterinary Internal Medicine
Time: ________________________
Patient Referral Form
DVM

Date: _________________________
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
mm / dd / yyyy
Weight:
kg
Hospital Name:
Phone:
Email:
Other veterinarians involved in this case:
* To better serve your client, please check the preferred specialty service on the left *
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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History and Physical Finding: _________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Laboratory / Radiographic / Biopsy Information: _________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Has the client been given an estimated fee for services?
YES
NO
BVSc, PhD
Diplomate, American College of
Veterinary Anesthesiologists
Diplomate, European College
Veterinary Anesthesia & Analgesia

If so, how much was quoted? ___________________________________________________________