CT Referral Form

Referral Instructions: When referring your patient to SAVE, please complete this online submission form. All pertinent medical records can be uploaded through this form or submitted via email to admin@saveveterinary.com.

Note: To ensure seamless service for your clients, we kindly ask that you complete this form and send it along with relevant medical records, blood work and radiographs prior to your client calling to schedule an appointment.

Date

Today

Urgency Level *

URGENT REFERRAL
NON-URGENT REFERRAL

Call ER to speak with an ER vet about urgent cases before transferring the patient.

Sites To Be Imaged *

Contrast *

Yes
No

CT Results will be sent to the referring practice to be followed up with pet owner.

REFERRING VETERINARIAN INFORMATION

DVM Name *

Referring Hospital *

Phone Number *

Email *

Does your client know that you are sending this referral? *

CLIENT INFORMATION

Owner's Name *

Co-Owner's Name

Address *

City *

Province *

Postal Code *

Phone Number *

Secondary Phone Number

Email Address *

PATIENT INFORMATION

Pet's Name *

Age/Date of Birth *

Species/Breed *

Gender *

Weight *

WAIT TIME ACKNOWLEDGEMENTS

Ensure your client was informed that for non-urgent cases, there may be wait times of 1-4 weeks for initial consultation and/ or procedure, but the clients will be contacted as soon as all medical records are received to advise of appointment timing. Urgent cases take priority over non urgent cases.

Client has been informed that for non-urgent cases the wait time can be between 1-4 weeks. *

REFERRAL INFORMATION

*diagnostic results will be sent to you to follow up with your client

Reason for referral/case details *

Relevant medical history and medication *

DOCUMENTS

Please upload any information such as medical records, lab results, or additional sheets.

Upload Files Here

Files Uploaded

Medical Records
Lab Results
Radiographs

Thank you for taking the time to complete this form. A member of our team will be in contact with you as soon as possible.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

CT Referral Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

WAIT TIME ACKNOWLEDGEMENTS

REFERRAL INFORMATION

DOCUMENTS

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