Veterinary Referral Form — Graham Animal Hospital

REPRODUCTION REFERRAL FORM

If you have a patient that you would like to refer to us for a consultation with our board certified theriogenologist, please fill out the form below & send medical records to repro@grahamanimalhospital.ca, and one of our team members will contact you.

Name and Clinic of Referring Veterinarian

Veterinarian Email

Veterinarian Phone

(###)

###

####

Name of Owner

First Name

Last Name

Owner's Email

Owner's Phone

(###)

###

####

Pet's Name

Species

Breed

Sex

Male

Female

Male Neutered

Female Spayed

Age / Date of Birth if known

Weight (kg)

Reason for Referral

Please send a full medical history and any diagnostic images to repro@grahamanimalhospital.ca

Clinical Exam Findings

Presentation, Physical Exam Findings, etc.

Current Medications

Any medications patient is currently on, or that has been administered in the last 24 hours.

Additional Notes