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: *

Weight client, with

Species *

Canine
Feline

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

Orthopedic consultation and surgical intervention (including TPLO where indicated) are performed to restore comfort, mobility, and long-term function.

Please note that orthopedic procedures are not performed by a board-certified surgeons.

Reason for Referral *

Orthopedic Surgery Requested *

Tibial Plateau Leveling Osteotomy (TPLO)
Femoral Head Osteotomy (FHO)
Fracture Repair
Limb Amputation

Brief Medical History *

Current Medications & Supplements *

Anesthetic History / Concerns / Drug Preferences (if applicable) *

Has the patient had any of the following within the past 6 months? *

Has the patient been diagnosed with any of the following conditions? *

If other, please specify *

Has the patient shown any of the following symptoms? *

If other, please specify *

Relevant Lab Findings *

Relevant Radiographic Findings *

Additional Requests

Specific Requests or Additional Comments

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 patient must be fasted for 12 hours prior to the procedure (unless otherwise directed).
The client has been advised that general anesthesia is required for orthopedic surgical procedures.
The client understands that discharge instructions will be provided by Central Veterinary Services following surgery.
Post-operative recheck appointments (including but not limited to suture/staple removal and post-op radiographs) will be scheduled directly with the Central Veterinary Services team.
The surgical report will be forwarded to the referring veterinarian within 24 hours.

Medical Records Upload *

Drag & Drop Files, Choose Files to Upload

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

Declaration

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.

TPLO/Orthopedic Procedure Referral Form

Fill out the form below.

Referring Hospital Information

Client Information

Patient Information

Clinical History & Indication

Additional Requests

Important Notes & Confirmations

Declaration

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