Veterinary Referral Form Referring Hospital* Referrer Email* Referring Veterinarian* Client Information Client Name* First Last Client Phone*Client Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient Name* Signalment Species* Date of Birth / Age Breed* Gender*MaleFemaleWeight (kgs) HiddenType of Services Requested (consultation, surgery, ultrasound, etc) Diagnostic Imaging and Laboratory WorkImaging / Laboratory Results Drop files here or Select files Max. file size: 256 MB. Type Radiographs CT MRI Ultrasound Blood Work Cytology Histopathology Other Requested ServicesType of Services Requested* Consultation Surgery Advanced Imaging Type of Scan Requested* Ultrasound CT MRI Area(s) to Be Scanned* Brain Cervical Spine Thoracic Spine Lumbar Spine Head Abdomen Thorax Shoulder Elbow Carpus Pelvis Stifle Tarsus Other Specify Location Specify Side* Right Left Area to Be Scanned* Reason for Requesting Scan*Please be as detailed and comprehensive as possible.Is an examination and consultation with one of the Tier 1 VMC doctors or specialists desired prior to the advanced imaging?* Yes No Patient HistoryPresenting Complaint*Onset and Duration of Problem*Current Medications and DosagesOngoing or Additional Medical Conditions Allergies Seizures Cardiac Problems Skin Condition Other Additional medical history pertinent to the case or anesthesia safetyCheck the box below to indicate that you have read and agree to the terms listed.* I have read and agree to the terms listed below. 1. Due to the need for injectable and/or gas anesthesia for advanced imaging and the use of contrast agents, a current (within 1 month) CBC/biochemistry and urinalysis is required. Risks of using contrast agents may lead to acute renal failure or anaphylactic shock. 2. All medical records and current bloodwork/urinalysis are required prior to scheduling imaging. Please send all information to [email protected] 3. As the referring veterinarian, I understand that without an examination and consultation with a Tier 1 doctor or specialist, I take full responsibility for the general health of this patient and that this patient is safe to undergo anesthesia. I also understand that I am responsible for the decisions regarding what imaging modality to use and what anatomy to image. Tier 1 will not be discussing the imaging results with the client or making recommendations and will forward the results to me as soon as they are available. 4. To improve efficiency, Tier 1 will communicate only with the doctor/clinic requesting the imaging and not the client.