This form is used to determine the urgency of the consultation.

The medical record will be consulted by the team only at the time of the consultation.

Please note that it is not possible to save the form to continue later. We therefore suggest that you write the information in a Word file and save it if you plan to write it in several steps.

This form is exclusively reserved for veterinarians and staff of veterinary clinics. Referral requests completed directly by owners will not be processed.

If your animal requires a referral to our specialist services, please contact your regular veterinarian. Thank you for your understanding.

*: required field

Web page of Internal Medicine Service
Web page of IR Service (for veterinarians only)

Examples of interventional procedures:

  • Cystoscopy
  • Removal of urinary stones by minimally invasive methods (lithotripsy and percutaneous cystolithotomy)
  • Treatment of incontinence and difficulty in urinationLaser surgery (masses, strictures, ectopic ureter, etc.)
  • Stent (trachea, urethra, ureter, blood vessels, etc.)

    Reason for referral: *

    REFERRING VETERINARIAN

    Veterinarian: *

    Referring clinic:

    Clinic phone number *:

    Other phone number:

    Email address*:

    CLIENT INFORMATION

    First name and last name*:

    Phone number #1 *:

    Phone number #2:

    Email address of the client:

    Other important information:

    PATIENT INFORMATION

    Name of the animal*:

    Check if already a patient of the CHUV:
    référé

    Species *:

    Breed (if known):

    Age or date of birth):

    Weight *:

    Sex *:

    Anamnesis *:

    Case history, active medical issues*:

    Treatments administered :

    Current medication, doses, frequency of administration and length of administration:

    Laboratory tests performed (check please) Please send us all lab results as attached files, if available. :

    Other: please specify:

    Imaging tests performed (check please) Please send us all imaging reports and images, if available. :

    Summary:

    Other relevant information :

    I confirm that I have obtained prior permission from the animal's owner to communicate this information*:

    Please attach a copy of the medical file including imaging and laboratory tests (en .pdf, .jpg, .doc, .docx, .xls, .xlsx, 4 MB per file maximum).

    You can also send them to us by email at admission-medecine-hac@chuv.umontreal.ca with the name of the patient and the department to which they are referred in the subject line.




    We will contact the owner to offer an appointment. However, you will be notified if we are unable to see the animal within a reasonable time frame based on its condition.