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Oncology Referral Form

The goal of an oncology consultation is to discuss treatment options and prognosis for a specific type of cancer. In order to provide the best medical care for our patients and their families, a diagnosis of cancer, completed referral form by a DVM or LVT familiar with the case and receipt of all medical records/documentation are required prior to scheduling.

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Primary Care DVM Oncology Referral Form

Please fill out the form as completely and accurately as possible so we can get to know your patient prior to the appointment.

Download & Print Form

If you choose to download and print the form, you can fax to 434-260-3822 or scan and email to info@vavetspecialists.com.

Date *

Patient Information

Patient's Name *

Species *

Breed *

Age *

Color *

Sex *

Weight *

Owner Information

Owner’s Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Referring Veterinarian Information

Primary Care Veterinarian *

Hospital Name *

Phone *

Fax

Name of person completing this form: *

Referral Checklist (please verify each bullet point and attach appropriate documentation):

The primary reason for referral is related to a recent diagnosis of cancer. Please select one of the following:

The primary reason for referral is related to a recent diagnosis of cancer. Please select one of the following:

Official, finalized pathology report (cytology, histopathology, PARR, flow cytometry, etc). *All in-house cytology samples must be submitted for interpretation by a pathologist prior to oncology referral.*

Diagnosis

The primary reason for referral is related to a recent diagnosis of cancer. Please select one of the following:

Urinary bladder mass and detection of mutated cells on urine Cadet BRAF analysis, suggestive of urothelial carcinoma.

The primary reason for referral is related to a recent diagnosis of cancer. Please select one of the following:

Aggressive, monostotic lesion affecting the metaphyseal region of the appendicular skeleton (e.g. proximal humerus, distal radius, distal femur, proximal tibia) in a large or giant dog, suggestive of osteosarcoma.

This patient is current on core vaccines:

Rabies Date (required by law)*

Rabies Administration Date *

DHLPP Administration Date

FDV Administration Date

This patient had a negative heartworm test within the past 12 months.

Date Performed:

This patient is otherwise stable. Please call if this is an urgent referral.

This patient is not currently receiving Apoquel.

This patient is not currently eating a raw or grain-free diet.

Diagnostics & Pertinent Medical History

Please select if any of the following additional diagnostics have been done within the last 6 months and forward all results/records *

CBC/chemistry
Abdominal ultrasound
Urinalysis
3D imaging (CT or MRI)
FeLV/FIV test
Chest x-rays
Other

If other, please explain

Please list all medications this patient is currently receiving (drug name, dose, frequency) *

Does this patient have other significant medical problems that are not well-controlled? Examples: hyperthyroidism, diabetes mellitus, heart failure, etc. *

Is this patient currently under the care of another oncologist or specialist? *

Please provide any additional information that may be helpful in facilitating the referral of this patient *

Upload Patient's Medical Records

Click or drag files to this area to upload. You can upload up to 10 files.

We proudly serve the pets of

Charlottesville, VA. and beyond.

It is our mission to partner with our clients to nurture and preserve the human-animal bond by providing compassionate, expert, and specialized veterinary care from your pet's first adventure throughout a long and healthy life.

Get In Touch

Our team is here to help.

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Email

info@vavetspecialists.com



address

370 Greenbrier Dr. Charlottesville, VA. 22901

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Phone

434-202-2987

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Hours

Mon - Fri :
7:00am – 6:00pm

Sat - Sun : Closed

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