Referring Veterinarian

New Case Submission

Referring Veterinarian

New Case Submission

Case Information

Note: This form is for veterinary use only. Pet owners please use the general question submission on the contact us tab.

Referring Clinic Name

Referring DVM

Clinic Email

Clinic Phone Number

Owner’s information

Pet’s information

Name

DOB/Age

Breed

Species

Sex

Current Weight in kg

Are you looking for a consult, surgery, or both?

Case Information

Case Summary

Patient’s current problem list

List any prior significant medical history

List and describe any prior surgeries. Please attach PDFs for all surgical reports that you have

List current medications with dosage & frequency

Imaging

Radiographs Taken?

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Ultrasound performed?

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Advanced imaging(CT/MRI/endoscopy)

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Diagnostics

Full Bloodwork (Minimum Chem/CBC)

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Cytology/Biopsy

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Any scheduling restrictions or preferences?

How did you hear about us?

If other, please elaborate

Any additional records you would like to submit

Note: All case submissions must contain all information listed above. Any incomplete forms will require a resubmission prior to scheduling

Referring Veterinarian

New Case Submission

Referring Veterinarian

New Case Submission

Case Information

Have Questions?

Have Questions?

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