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Referral Form

Patient Information

Patient Sex
Include duration of problem, progression, any treatments, and response to treatment.
Onset
MM slash DD slash YYYY

Client Information

Client Name(Required)

Referring Hospital Information

Referral Department
Patient should be seen

Relevant Documents

Please attach patient history, medical findings, and images below, or by email to pets@orchardvetcare.ca for fastest turnaround.
Drop files here or
Max. file size: 5 GB.