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.

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

Referring Hospital

Owner Information

Patient Information

Patient Demeanor

If the patient falls into the high energy, nervous or aggressive categories, or if the patient might qualify for a same day minor procedure, we would appreciate it if you could provide the patient with the send-home oral sedation to be given prior to their visit. ie. Gabapentin / Trazodone or other sedation per your judgment

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.

Click or drag files to this area to upload. You can upload up to 5 files.