Patient Referral Form

Please fill out this form to refer a patient to True North
Veterinary Eye Care. Thank you!

Patient Referral Form

Thank you for entrusting True North Veterinary Eye Care with your patient’s ophthalmology care. We look forward to working with you to provide the best possible care for this patient. Please fill out the questionnaire below and ask the client to complete the following forms on our website.

Request an Appointment New Patient Questionnaire

Once we have seen the patient, we will email a visit summary to both you and the client.

Referring Hospital

Referring Doctor’s Name *

Clinic Name *

Phone number *

Email *

How do you prefer to be contacted about this case?

Owner Information

Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Owner Phone number *

Owner Email *

Patient Information

Name *

Species *

Breed *

Gender/Neuter Status *

Date of Birth / Age *

Patient’s Most Recent Weight (in kg) *

Date Weight was Taken: *

Patient Demeanor

As our exams place us nose to nose with our patients and patients may need to sit perfectly still, what is the patient’s temperament? Please select the appropriate description for this patient. *

If the patient was difficult (ie: wiggly, aggressive, excited, nervous, head shy, etc) we require you, the primary care veterinary, to send home oral sedation appropriate for the patient (ie: Gabapentin & Trazodone the night before and 2hrs before appointment), to accomadate our exam. As we do not have a Veterinary Client Patient Relationship we can not prescribe any sedation prior to the appointment.

If sedation is being provided, please include the concentration and dose (in mg/kg), as well as the instructions provided to the client below.

Patient History

We appreciate you taking the time to fill out the below questions to help us get to know this patient. However, as we know schedules are hectic, if you are short on time, please fill out the required fields and attach an electronic copy of relevant records for our review.

Based on your assessment, when should this patient ideally be seen? Please check the appropriate timeframe. *

When did signs start?

What is this pet’s ophthalmic medical history? Please list eye(s) affected, tentative diagnosis, procedures/surgeries, etc.

If applicable, what diagnostics have been performed? Please indicate date and result.

What medications has the pet been on to address their ocular disease? Please indicate which eye was treated, dose, frequency, as well as start/end dates. What was the response?

What is the patient’s relevant systemic disease history?

What oral or systemic medications is this pet on? Please provide the name, dose and frequency.

Does this patient have any food allergies or history of adverse drug reaction?

Has this patient needed any recent blood work or other non-ophthalmic diagnostics? What were the results?

If the pet is potentially heading to surgery, what is your assessment of Anesthetic risk? Please provide your estimated ASA status. *

If the pet is diabetic and potentially heading to surgery, how well controlled would you consider their diabetes? Please provide the following: insulin type / dose / frequency, glucose curve summary (peak, last performed date), fructosamine, etc. *

Do you feel comfortable if this patient receives a short course of injectable/oral NSAIDs if needed for pain management without further bloodwork? Please indicate if NSAIDs are contraindicated in this patient and/or specify if you recommend that this pet return to your clinic for further blood work before any NSAIDs are prescribed *

Is there anything else you think we should know?

Please attach any relevant photos, records and labwork.

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Patient Referral Form