Referring veterinarian's name

Referring Clinic's name

Referring Hospital's phone number

Referring Hospital's email

Owner's name

Owner's email

Owner's phone number

Patient's name

* Species * Species *CanineFelineOther

Breed

* Sex * Sex *MaleMale neuteredFemaleFemale spayed

date of birth

Patient's weight

Please indicate the reasons for the referral

Concern duration

Physical Exam (Specify exam dates and main findings only)

Rectal performed Yes / No (Findings?)

Laboratory Tests: (Attach results if available)

Recent CBC: Recent CBC: Yes No

If yes, describe main abnormalities including values

Chemistry Panel: Chemistry Panel: Yes No

If yes, describe main abnormalities including values

Other tests (describe)

Previous Radiographs: Please make sure to attach any available images and reports available Previous Radiographs: Please make sure to attach any available images and reports available Yes No

Date:

Findings:

Date:

Findings:

Previous Ultrasounds: Previous Ultrasounds: Yes No

Current Medications: Current Medications: Yes No

Medication / Dose / Duration

Other Imaging (CT/MRI):

Prior Surgeries: Prior Surgeries: Yes No

If yes, please specify (Procedure/Date)

Recent/Ongoing Treatments( Skin treatment, Chemotherapy, Rehab/physio):

If yes, please describe

Coagulopathy Risk| Known bleeding disorders or abnormal coagulation tests: Coagulopathy Risk| Known bleeding disorders or abnormal coagulation tests: Yes No

Anesthetic/Sedation History | Previous reactions to sedation/anesthesia: Anesthetic/Sedation History | Previous reactions to sedation/anesthesia: Yes No

Infectious Diseases | Known/suspected infectious diseases: Infectious Diseases | Known/suspected infectious diseases: Yes No

If yes, please describe

Allergies | Known drug or material allergies: Allergies | Known drug or material allergies: Yes No

If yes, please describe

Behavioral Concerns | Handling precautions or aggressive behaviors: Behavioral Concerns | Handling precautions or aggressive behaviors: Yes No

If yes, please describe

Additional relevant information

Suspected Conditions/Differential Diagnoses:

Specific Organs/Regions to Focus On:

Procedures Requested: Procedures Requested: Diagnostic Ultrasound Fine Needle Aspirate(s) Tru-cut Biopsy(ies) (Requires discussion/approval by radiologist; typically requires general anesthesia) Cystocentesis

Other Procedures:

If aspiration or biopsy requested, recent PT/PTT test performed: If aspiration or biopsy requested, recent PT/PTT test performed: Yes No

Samples/slides to be sent by: Samples/slides to be sent by: OAESH Family Vet

Attachments (Please ensure the following are included) - Complete Medical History | Laboratory Results | Previous Imaging Studies | Other Relevant Documents UploadPatient file, blood results, other files...Accepted files : jpg, jpeg, jpe, png, pdf, docx. Max. file size: 20 MB

Contact Preferences (Please enter veterinarian name here)

For legal reasons, this form must be completed and signed by the referring veterinarian. Forms completed by support personnel (including veterinary technicians or administrative staff) will not be accepted and your referral request may be rejected. For legal reasons, this form must be completed and signed by the referring veterinarian. Forms completed by support personnel (including veterinary technicians or administrative staff) will not be accepted and your referral request may be rejected. Phone Email Fax

Urgency Level: Urgency Level: Routine Urgent

If urgent, specify reason: (This does not promise an earlier slot)

Please type your name as your signature.