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.

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.

    Date of appointment, if already given:

    Reason for referral:*



    Referring clinic:

    Clinic phone number*:

    Other phone number:

    Email address*:


    First name and last name*:

    Phone number #1*:

    Phone number #2:

    Email address of the client:


    Name of the animal*:

    Check if already a patient of the CHUV:


    Breed (if known):

    Age or date of birth*:




    Current diet of the patient:

    Does the animal have an exercise or stress intolerance?

    Does the animal have a cough?

    Does the animal have collapse episodes?

    Does the owner take the resting respiration rate?

    If so, what is it?

    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. :


    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 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.