Vision VetCare Referral Form

Please complete the referral form below to request an ophthalmology consultation. Providing detailed history and current concerns allows us to deliver the highest level of care and keep you informed every step of the way.

Referring Clinic Name

Referring Veterinarian:

Referring Clinic Email

Referring Clinic Phone Number

Patient's Name

Client's Name

Client's Phone #

Client's Email

Pet Insurance

Yes

Unknown

**If YES- please list Insurance company

Age/Sex/Species/Breed

URGENCY

Less than a week, if available

1-2 weeks if available

up to 1 month

FAS SCORE:(FEAR/ANXIETY/STRESS)

GREEN- Mild/Relaxed

YELLOW- Moderate/Caution

RED- Severe/High

Pre-Visit Medications are MANDATORY 2hrs prior to every visit to help ensure a positive exam and aid with travel. Please call if dosing questions- Thanks!

Brief Summary

Relevant Medical History Upload:

Recent Labwork Upload:

Relevant Photos/Videos Upload:

Consultation fee: $342 + tax. This visit includes a detailed eye exam with Schirmer Tear Test, fluorescein stain, and initial tonometry. Additional diagnostics and medications, if required, are not included and will be discussed prior to proceeding.

**Eye consultations are provided in collaboration with the referring veterinarian. Routine wellness care, vaccinations, preventative medicine and general health management will remain under the direction of the referring veterinarian provided by the primary care clinic. Thank you again!

Vision VetCare

by Dr. Emily Wagler, DVM

Bridging the gap between primary care veterinarians and Board Certified Ophthalmologists by offering Ophthalmic services in Southwestern, Ontario.

Vision VetCare Referral Form