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

If you are interested in referring a patient to our team for treatment, please fill out the form below or call our office to be placed in touch with the appropriate veterinarian.

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 *

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

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Dentistry

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 *

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

Spam Blocker
Neurology

Patient Information

Pets Name *

Age *

Weight (KG) *

Sex *

Species *

Breed *

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 *

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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 *

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

Spam Blocker

Specialty Veterinary Referrals

For Referring DVMs

Print & Complete

Cardiology

Dentistry

Neurology

Surgery

Complete Online

Referring Veterinarian

Patient Information

Patient Information

Referring Veterinarian

Patient Information

Patient Information

Patient Information

Client Information

Referring Veterinarian

Referring Veterinarian

Patient Information

Patient Information

Emergency & Specialty Veterinary Referrals Welcome