Oncology Patient Referral Form Please enable JavaScript in your browser to complete this form.Client & Patient InformationClient Name *FirstLastClient PhonePatient NameSpeciesBreed, Age, & GenderReferring Doctor InformationPrimary DVM *Referring Hospital:DVM Phone: *E-mail: *DVM Fax:Cancer Type & Location:Date of Diagnosis:Recurrent Tumor: YesNoOther health concerns:Diagnostics done prior to referral – please check all that apply:BiopsyFNA/cytologyCBCSerum ChemistryU/ACT scanMRIUltrasoundLymph Node aspiratesX-raysOther (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?YesNoIf so, describe:Any known adverse reactions to medication or anesthesia? YesNoCurrent medications and supplements:Brief Case SummaryMessageSubmit