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250-266-3911
info@westcoastaec.ca

REFER A PATIENT

Veterinarians

Appointment locations are available in Victoria,

Qualicum Beach, Vancouver and Surrey.

Pet Owners
Please do not fill out this form yourself.

If you think that your pet requires an eye exam, please discuss this with your primary care veterinarian or send us an email.

Will My Regular Veterinarian Still Be Involved?

We will work together with your veterinarian as part of your pet's total veterinary health care team. Your primary care veterinarian will still oversee all aspects of your pet's care, but with our added input. For example, if we diagnose diabetes in your pet as a result of an eye examination for cataracts, that information will be relayed back to your primary care veterinarian who will treat your pet's diabetes. The additional input of our practice will be called upon as needed as your veterinarian manages your pet's illness.

Anchor 1

Referral Form

Clinic Information

Referring Clinic Name

Referring Veterinarian First Name

Referring Veterinarian Last Name

Referring Clinic Email Address

*Please use the best hospital email address for correspondence regarding scheduling and confirmation of the appointment.

Referring Clinic's Phone Number

Referring Clinic Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Patient Information

Patient Name

Species

Breed

Colour

Date of birth

Year

Month

Day

Gender

Weight (kg)

Suspected diagnosis / Presenting complaint

History

Medications

Owner Information

First name

Last name

Phone Number

Email

Address

Country/Region

Address

City

Zip / Postal code

Select an option

Medical Record

*If additional records need to be sent, please email them to info@westcoastaec.ca

Photos

*If additional photos need to be sent, please email them to info@westcoastaec.ca

Click submit button ONCE and look here for submission confirmation

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