Name: Burlington Veterinary Emergency & Referral Hospital
Address: 775 Woodview Rd, Burlington, ON, L7N 3S1, CA
Telephone: (905) 637-8111

Cardiology

Referring Veterinarian

Doctor Name

Hospital Name

Referring Veterinarian Email

Referring Veterinarian Phone

Patient Information

Client (Owner) First Name

Client (Owner) Last Name

Client (Owner) Email

Client (Owner) Primary Phone

Client (Owner) Secondary Phone

Client Address

Patient Information

Pets Name

Species

Sex

Breed

Colour

Date of Birth dd/mm/yyyy

Weight (KG)

FELV / FIV Testing Completed?

Yes

No

Not Applicable

Does this patient require a muzzle or sedation for an exam?

Yes

No

Presenting Complaint

Reason for Referral

Current Medications & Treatment

Diagnostics (Please include if applicable):

Labwork (blood, cytology, histopathology, etc...)

Dental Radiographs

Other Imaging (Rad/US/CT/MRI)

Imaging Reports

Special Requests or Comments

Upload Medical Records
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Upload any Relevant Diagnostics (if not in MR)
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Upload any Relevant Imaging (if not in MR)
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Upload Any Other Corresponding Documents. If You Have Additional Documents, Please Combine Them into a ZIP folder.
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Dentistry

Referring Veterinarian

Please send patient records, diagnostics, and images to us using the below referral form. If you prefer to transfer records to our service via email, please contact us at (905) 637-8111 for instructions.

Doctor Name

Hospital Name

Referring Veterinarian Email

Referring Veterinarian Phone

Patient Information

Client (Owner) First Name

Client (Owner) Last Name

Client (Owner) Email

Client (Owner) Primary Phone

Client (Owner) Secondary Phone

Client Address

Patient Information

Pets Name

Species

Sex

Breed

Colour

Date of Birth dd/mm/yyyy

Weight (KG)

FELV / FIV Testing Completed?

Yes

No

Not Applicable

Does this patient require a muzzle or sedation for a full oral exam?

Yes

No

Presenting Complaint

Reason for Referral

Current Medications & Treatment

Diagnostics (Please include if applicable):

Labwork (blood, cytology, histopathology, etc...)

Dental Radiographs

Other Imaging (Rad/US/CT/MRI)

Imaging Reports

Special Requests or Comments

Upload Medical Records
Browse...

Upload any Relevant Diagnostics (if not in MR)
Browse...

Upload any Relevant Imaging (if not in MR)
Browse...

Upload Any Other Corresponding Documents. If You Have Additional Documents, Please Combine Them into a ZIP folder.
Browse...

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Neurology

Patient Information

Pets Name

Age

Weight (KG)

Sex

Species

Breed

Colour

Relevant Patient History

Current Medications

Does this patient require a muzzle or sedation for examination?

Yes

No

Clients expectations of this appointment

Please upload any labwork and diagnostics
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Client Information

Client (Owner) First Name

Client (Owner) Last Name

Client (Owner) Primary Phone

Client (Owner) Secondary Phone

Client (Owner) Email

Client Address

Referring Veterinarian

Doctor Name

Hospital Name

Referring Veterinarian Email

Referring Veterinarian Phone

Upload Medical Records
Browse...

Upload any Relevant Diagnostics (if not in MR)
Browse...

Upload any Relevant Imaging (if not in MR)
Browse...

Upload Any Other Corresponding Documents. If You Have Additional Documents, Please Combine Them into a ZIP folder.
Browse...

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Surgery

Referring Veterinarian

Doctor Name

Hospital Name

Referring Veterinarian Email

Referring Veterinarian Phone

Patient Information

Client (Owner) First Name

Client (Owner) Last Name

Client (Owner) Email

Client (Owner) Primary Phone

Client (Owner) Secondary Phone

Client Address

Patient Information

Pets Name

Species

Sex

Breed

Colour

Date of Birth dd/mm/yyyy

Weight (KG)

FELV / FIV Testing Completed?

Yes

No

Not Applicable

Does this patient require a muzzle or sedation for an exam?

Yes

No

Presenting Complaint

Reason for Referral

Current Medications & Treatment

Diagnostics (Please indicate if applicable):

Labwork (blood, cytology, histopathology, etc...)

Dental Radiographs

Other Imaging (Rads/US/CT/MRI)

Imaging Report

Special Requests or Comments

Upload Medical Records
Browse...

Upload any Relevant Diagnostics (if not in MR)
Browse...

Upload any Relevant Imaging (if not in MR)
Browse...

Upload Any Other Corresponding Documents. If You Have Additional Documents, Please Combine Them into a ZIP folder.
Browse...

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Specialty Veterinary Referrals

Complete Online (Preferred)

Referring Veterinarian

Patient Information

Patient Information

Referring Veterinarian

Patient Information

Patient Information

Patient Information

Client Information

Referring Veterinarian

Referring Veterinarian

Patient Information

Patient Information

Print & Complete

Cardiology

Dentistry

Neurology

Surgery

Emergency & Specialty Veterinary Referrals Welcome