Emergency and Critical Care Patient Transfer Form

If you are a client’s regular veterinarian and wish to transfer a patient to Bridgwater Veterinary Hospital & Wellness Centre for overnight care, further diagnostics, or other, please complete this form.

If you have any questions about the referral of specific cases, feel free to phone ahead and speak to one of our veterinarians.

Note: If a patient is stable when the referring veterinary hospital reopens, the patient’s transfer will be arranged at request. Patient transportation is an owner’s responsibility. If a patient is not stable for transfer, they will remain in care at Bridgwater Veterinary Hospital and Wellness Centre.

REFERRING VETERINARIAN INFORMATION

Name of referring hospital *

Name of Referring Veterinarian *

Phone Number *

Fax Number

Email Address of Referring Veterinarian *

Owner's Full Name *

Co-Owner's Name

Address *

City *

Province *

Postal Code *

Phone Number *

Secondary Phone Number

Email Address *

Patient Notes (i.e. Caution)

Patient is *

Critical
Stable

Referral Reason *

Patient is critical
Possible surgical intervention required
Patient needs 24 hr care

Presenting Complaint *

Current/Relevant History & Medication

CBC *

Chemistry *

Electrolytes *

Blood Gas *

T4 *

CPL/FPL *

UA *

Tentative Diagnosis

Drugs Given | Dose/Route | Frequency | Time Given | Next Dose Due

DOCUMENTS

All records must be received prior to the patient's arrival.

Upload Files Here

Checklist

Medical records have been uploaded/sent
Bridgwater VH has been called and notified of estimated time of arrival
Client has been informed that if the animal is stable and Bridgwater VH has another critical patient, there may be a wait

Special Requests or Additional Comments

Is the patient being transferred back to your facility? *

Yes
No

Thank you for taking the time to complete this form. A member of our team will be in contact with you as soon as possible.

Emergency and Critical Care Patient Transfer Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

DOCUMENTS

Emergency and Critical Care Patient Transfer Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

DOCUMENTS

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