Referral Form

We will contact the client to schedule an appointment once this form has been submitted.

Please note: If you are a client looking to schedule your pet for a consultation, please ask your primary care veterinarian to submit a referral. We will reach out to you once a referral is received.

Veterinary Clinic Information

Is this your first time submitting a referral to Bright Light Veterinary Eye Care? *

Clinic Name *

Veterinarian's Name *

Clinic Email Address *

Clinic Phone Number

Client Information

Primary Client Name *

First

Last

Secondary Client Name (Optional)

First

Last

Client Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Client Email *

Primary Phone Number *

Secondary Phone Number (Optional)

Patient Information

Name *

What type of patient are you referring? *

Small animal (canine, feline, pocket pet, or exotic)
Large animal (horse or other farm animal)
Other (please describe under "Breed")

Breed *

Date of Birth *

Colour

Sex *

Patient History

Working Diagnosis

Current Systemic Medications

Current Ocular Medications

Please attach patient records, as well as images and diagnostic test results if applicable. If file is not yet complete, please email all documents and information to care@brightlightvet.ca once finalized.

Patient records

Click or drag files to this area to upload. You can upload up to 5 files.

Sending records: *

Records are attached
Records to follow

Additional Comments

Please note: If the patient is fearful, reactive, or very wiggly, we appreciate your support in prescribing pre-visit medication(s) to allow for a thorough and fear-free consultation.