306-745-6642 tvvstaff@sasktel.net

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Referral Form

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Referral Form

Date *

Doctor Name *

First

Last

Practice Name *

Laboratory Name

Doctor E-mail *

Doctor Phone *

Doctor Fax

How would you like to be contacted?

Phone
Email
Fax

Client Name *

First

Last

Patient Name *

First

Last

Patient Species *

Dog
Cat
Other

Please upload lab reports, x-rays, and other diagnostics.

Drag & Drop Files, Choose Files to Upload

Additional Upload (if necessary)

Drag & Drop Files, Choose Files to Upload

Additional Upload (if necessary)

Drag & Drop Files, Choose Files to Upload

Additional Upload (if necessary)

Drag & Drop Files, Choose Files to Upload

Patient History

Diagnostic Information

Treatments / Medications

As the referring veterinarian, my expectations for this case are as follows: (Please check one.)

Referral for procedure(s)
Hospitalization and definitive care
Overall management of care for the diagnosis
Overnight care and return in the morning

Is there any more information we should know?

Comment

Questions?

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Contact

Phone: 306-745-6642
Fax: 306-745-6643
E: tvvstaff@sasktel.net

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Location

424 Maple Street
Esterhazy, Saskatchewan
S0A 0X0

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Opening Hours

Monday: 8:00 am – 5:00 pm
Tuesday: 8:00 am – 12:30 pm; 1:30 pm – 5:00 pm
Wednesday to Friday: 8:00 am – 5:00 pm
Saturday-Sunday: Closed

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