Endoscopy Referral Form

When referring your patient to our hospital, please complete this form along with all pertinent medical records. If you have any questions while completing this form, please reach out to us at 204-452-0911 or send an email to info@bridgwatervethospital.ca.

REFERRING HOSPITAL INFORMATION

Name of referring hospital *

Name of Referring Veterinarian *

Phone Number *

Email Address of Referring Veterinarian *

CLIENT INFORMATION

Client's Full Name *

Email Address *

Address *

City *

Province *

Postal Code *

Phone Number (Primary) *

Phone Number (Alternate)

PATIENT INFORMATION

Patient's Name *

Date of Birth or Age *

Species *

Breed *

Weight (kg) *

Sex *

Temperament *

caution, nervous, etc.

PATIENT HISTORY

Brief Medical History *

Does the patient have any pre-existing conditions?

Current medications prescribed and last time administered: *

Please upload the patient's medical records and any lab results

REQUESTED SERVICES

Endoscopy Service Requested: *

Cytoscopy
Otoscopy +/- Deep Ear Cleaning
Upper Gastrointestinal Tract with Biopsy
Upper Gastrointestinal Foreign Body Retrieval
Colonoscopy and Biopsy
Upper Airway / Rhinoscopy

Please check the box to confirm your client has been informed that it will take 24 - 48 hours for results to be forwarded to referring hospital. Bridgwater will not be reviewing FNA results with the client. They will be forwarded to the referring veterinarian *

Any Additional Comments?

If this patient is urgent, please call us immediately.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Endoscopy Referral Form

REFERRING HOSPITAL INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

PATIENT HISTORY

REQUESTED SERVICES

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