Name: Central Veterinary Services
Address: 8092 Perimeter Hwy, Oak Bluff, MB, R0G 1N0, Canada
Telephone: 204-275-2038
Price range: $

Thank you for trusting Central Veterinary Services with your patient’s care.

Please complete this form and attach all relevant medical records, laboratory results, and diagnostic imaging to support a thorough and timely assessment.

Once the referral and supporting records have been reviewed, our team will contact the client directly to coordinate scheduling. Please allow 24–48 business hours for processing.

If the case is urgent, we encourage you to contact us directly at 204-275-2038.

Referring Hospital Information

Name of Referring Veterinary Clinic *

Name of Referring Veterinarian *

Clinic Phone Number *

Clinic Email Address *

Detailed findings, case summaries, and referral updates will be sent to this email address.

Client Information

Client Name *

First

Last

Primary Phone Number *

Alternate Phone Number

Email Address *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Information

Patients Name: *

Species *

Canine
Feline
Equine

Breed: *

Crossbreeds

Sex: *

Male
Female

Reproductive Status *

Neutered
Not Neutered
Unknown

Age or Date of Birth *

Coat Colour *

Microchip #

Tattoo #

Allergies

Weight (kg) *

Clinical History & Indication

Endoscopy allows for minimally invasive visualization of internal structures and may support both diagnostic and therapeutic intervention.

Please note that scans are not interpreted by a board-certified radiologist.

During endoscopic procedures, the attending veterinarian will almost always collect biopsy samples for submission to our referral laboratory for histologic evaluation. Biopsies are sent away to Antech Reference Lab for histological evaluation by board-certified pathologists. While endoscopy provides detailed visualization, appearance alone is not diagnostic. Histopathology allows us to confirm underlying disease and provide clear, evidence-based treatment recommendations.

Tentative Diagnosis / Primary Concern *

Endoscopy Service Requested

Choose Species *

Canine/Feline
Equine

Canine/Feline: *

Upper Gastrointestinal Endoscopy
Colonoscopy
Rhinoscopy and Reverse Nasopharyngoscopy
Otoscopy

Equine: *

Gastroscopy
Upper Airway

Brief Medical History *

Current Medications & Supplements *

Anesthetic History / Concerns / Drug Preferences (if applicable)

Relevant Lab Findings *

Relevant Radiographic Findings *

Additional Requests

# Weight Preferences

Specific Questions You Would Like Addressed

Important Notes & Confirmations

To ensure a smooth experience for both your team, our team, and the client, please confirm the following have been discussed: *

Previous medical records and relevant diagnostic imaging must be received and reviewed prior to booking.
The canine/feline patient must be fasted for at least 12 hours, with no water for 4 hours prior to the procedure (unless otherwise directed). OR the equine patient must be fasted for at least 18 hours, with no water for 4 hours.
The client has been advised that sedation (equine) or general anesthesia (canine/feline) is required for endoscopic procedures.
Endoscopic findings in the form of a report will be forwarded to the referring veterinarian within 48 hours.
The client has been advised that results will not be available on the same day. Endoscopic findings and biopsy results will be communicated directly to the referring veterinarian. We will not review results with the client unless urgent medical circumstances require immediate discussion.

Medical Records Upload *

Drag & Drop Files, Choose Files to Upload

Please attach all relevant medical records, laboratory results, and diagnostic imaging.

Declaration *

I confirm that the information provided is accurate and complete to the best of my knowledge.

Declaration *

I have read and understood the Privacy Policy.

We appreciate the opportunity to collaborate in your patient’s care.

Endoscopic Procedure Referral Form

Fill out the form below.

Referring Hospital Information

Client Information

Patient Information

Clinical History & Indication

Endoscopy Service Requested

Additional Requests

Important Notes & Confirmations

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