Oncology Patient Referral Form

Client & Patient Information

Client Name *

First

Last

Client Phone

Patient Name

Species

Breed, Age, & Gender

Referring Doctor Information

Primary DVM *

Referring Hospital:

DVM Phone: *

E-mail: *

DVM Fax:

Cancer Type & Location:

Date of Diagnosis:

Recurrent Tumor:

• Yes
• No

Other health concerns:

Diagnostics done prior to referral – please check all that apply:

• Biopsy
• FNA/cytology
• CBC
• Serum Chemistry
• U/A
• CT scan
• MRI
• Ultrasound
• Lymph Node aspirates
• X-rays
• Other (specify below)

Please include all laboratory and other diagnostic reports. Radiographs will be promptly returned.

If Other, please specify:

Upload reports here:

Click or drag files to this area to upload. You can upload up to 15 files.

Please include all laboratory and other diagnostic reports. Radiographs will be promptly returned.

Any surgery other than spay?

• Yes
• No

If so, describe:

Any known adverse reactions to medication or anesthesia?

• Yes
• No

Current medications and supplements:

Brief Case Summary

Phone

Submit