Prescott Animal Hospital Large Animal Surgery & Medical Referral Centre a division of Leeds-Grenville Veterinary Professional Corp

Prescott Animal Hospital

Large Animal Surgery & Medical Referral Centre

A division of Leeds-Grenville Veterinary Professional Corp.
RR# 4

2725 Edward St. N.

Prescott, Ontario, K0E 1T0

[e-mail]

www.prescottvet.ca

Telephone [phone]

Fax [phone]
Referral and Emergency Transfers

Referring Hospital__________________________________ Referring DVM_____________________________

Clinic Email________________________________________ Clinic Phone #_____________________________

Client Information Patient Information
Name_________________________________ Name____________________________________________

Address________________________________ Breed____________________________________________

Address_______________________________ Date of Birth______________________________________

Phone #_______________________________ Color_____________________________________________

Email__________________________________ Sex M /F / MN (Circle one)

Last Tetanus Vaccine______________________________


Included Relevant Documents
Medical Records □ Radiographs □ Bloodwork □ Other □ Food□


Presenting Complaint_______________________________________________________________________________
Current/Relevant History__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current Treatments & Medications

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please indicate your preferred method of communication so we may update you on the status of your patient

□ Phone_____________ □Text_______________ □Fax_________________ □Email___________________________________

□Time_____________________________________