Referral Form

Name: Lakewood Veterinary Hospital
Address: 123 Vermillion Rd, Winnipeg, Manitoba, R2J 4A9, CAN
Telephone: (431) 441-3810

Thank you for trusting Lakewood Veterinary Hospital with your patient referral.
For any additional questions or concerns please call (431) 441-3810 or email [email protected].

Referral DVM *

DVM Phone *

DVM Email *

Referring Hospital Name *

Referring Hospital Phone *

Referring Hospital Email *

Referred For:

Medical Boarding

Ultrasound

Endoscope

Orthopedic

Client Name (First and Last) *

Client Phone *

Client Email *

Patient's Name *

Species

Breed

Sex

Female

Female Spayed

Male

Male Neutered

Unknown

Recommended or Requested Diagnostics *

Tentative Diagnosis/Chief Complaint *

History/Physical Findings *

Treatment (including medications and dosages) *

Special Requests/Comments (what are the client's expectations for Lakewood)

If available please attach the following: medical notes/records, imaging, lab work results, treatments (including last time
administered), applicable images, and videos.
*Note- attachments with spaces in the name will be rejected. Example- dog-image.jpg is accepted, dog image.jpg is not.

Please attach pertinent images below

One file only.
50 MB limit.
Allowed types: gif, jpg, png, svg.

Please attach pertinent documents below

One file only.
50 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Please attach pertinent videos below

One file only.
50 MB limit.
Allowed types: avi, mov, mp4, ogg, wav, webm.

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Referral Form

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