Referral Request Form | Oakpark Pet Hospital | Veterinary Clinic | Oakville

Referring Hospital Name^*

Referring Veterinarian^*

Referring Hospital Email Address^*

Referring Hospital Phone Number^*

CLIENT INFORMATION

Client Name^*

Client Email Address^*

Client Phone Number^*

CLIENT MAILING ADDRESS

Street Address

City

State

Zip

PET INFORMATION

Pet Name^*

Pet Age^*

Species

If other, please specify pet type

Breed^*

Sex^*

Weight(kg)^*

Colour Markings

Date of Birth

Rabies Vaccination Status^*

MEDICAL HISTORY

Reason for imaging referral (briefly describe history and relevant previous diagnostic tests)

List or describe relevant current or previous medical conditions

Current Medications

Allergies or previous anesthetic complications

REFERRAL SERVICES REQUESTED HDVI Scan (CT Scan) Fluoroscopy Other (specify)

Areas Of Interest
Dental (No Contrast)
Skull (Contrast - oral cavity, middle and inner ear, nasal cavity, brain)
Thorax
Abdomen
Orthopedic
Subcutaneous Mass
Other (specify)

Imaging Reports May Take 1-3 Business Days For Results

I understand that all imaging referral cases will be directed back to the referring veterinarian listed on this form for ongoing care and treatment.

PLEASE NOTE: general anesthesia is required for most Vimago studies - all patients will receive a complete physical examination and pre-anesthetic blood work prior to proceeding - in the event that an animal is not a candidate for anesthesia, the procedure may be cancelled or re-scheduled.

Thank-you for your referral! A client service representative will contact your hospital once this request has been reviewed by one of our veterinarians.

Referral RequestReferral Form

Vimago Imaging Referral Request

CLIENT INFORMATION

PET INFORMATION

MEDICAL HISTORY