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.

Please note that, if the patient’s follow-up is done by you following the consultation, please check the box to that effect.

Please note that in this case, client communication (treatment plan, modification/renewal of prescription, etc.) is the responsibility of the referring veterinarian and not the CHUV medical team.

However, we will be pleased to answer any questions you may have.

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

    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 :

    Concerning the specialised follow-up visits, I would like them to be carried out by*:

    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.