Forms

Surgery Referral Form

Refer a patient to Edmonton West Animal Hospital & Spay/Neuter Centre for a surgical procedure. Our team will review the case and follow up with you directly.

Referring Veterinarian & Clinic

Fields marked with * are required.

Referring Veterinarian *

Clinic Name *

Clinic Phone Number *

Clinic Email *

Client (Owner) Information

Owner's Name *

First *

Last *

Owner's Phone Number *

Owner's Email

Patient Information

Pet's Name *

Species *

Breed

Age / D.O.B.

Sex

Spayed / Neutered

Medical History & Reason for Referral

Surgical Procedure / Diagnosis *

Relevant Medical History, Medication, and Physical Exam Findings *

Current Medications

Diagnostics Performed (bloodwork, imaging, etc.)

Preferred Date (if any)

Appointment Availability

Patient Should Be Seen *

Next Available Appointment

If this referral is urgent or requires same-day or immediate attention, please call our hospital at (780) 488-0124 or email us directly at [email protected] to confirm availability.

Records & Attachments

Attach any supporting medical records, bloodwork, radiographs or lab results below, or email them to [email protected] referencing the patient's name.

Attachments

Tap to attach filesPDF, Word or image files — up to 10 files, 10MB each

Authorization

I confirm the information provided above is accurate to the best of my knowledge, and I authorize Edmonton West Animal Hospital & Spay/Neuter Centre to contact the referring clinic and/or pet owner regarding this referral.*

I acknowledge that Edmonton West Animal Hospital & Spay/Neuter Centre is a general practice veterinary hospital and not a specialist referral centre. Surgical procedures and ultrasound/echocardiogram services are performed by our general practice veterinarians. If the client requires evaluation or treatment by a board-certified specialist, they should be referred to an appropriate specialty referral hospital.*

Verify you are human *