Oncology Referral Form

Please complete the online form and click the "Submit" button at the bottom of the page. You will receive a confirmation email message immediately after submitting your referral form. 

If you have any questions or problems completing this form, please contact vmccorrespond@usask.ca.
 
Fields marked with a red asterisk must be completed before submission.

Confirmation Email Address:?
Referring Veterinarian's Information
Name
Phone
Fax
Hospital name
Address
City/town
Province
Postal code
Client Information
Client name
Address
City/town
Province
Postal code
Preferred phone Cell
Home
Work
Preferred #
Alternate phone Cell
Home
Work
Alternate #
Client email
Patient Information
Patient name
Species
Breed
DOB
(01 Jan 2014)
Gender M
F
NM
NF
Weight (kg)
Colour
Date of initial presentation for the problem
(01 Jan 2014)
Patient history and findings
Tumour type
Disease type Gross disease
Microscopic disease
PDS lab #
Tumour diagnosis based on Cytology
Histopathology
Radiology
Was the tumour surgically resected prior to referral? Yes
No
Date(s) of previous surgical resection(s)
Tumour size (__cm x __cm x __cm)
If surgically resected, please indicate size prior to resection
Tumour location
Staging Completed Prior to Referral
Please check each test for which you can provide results Tumour biopsy/histopathology
CBC, blood chemistry
Urinalysis
FeLV/FIV/T4 (feline)
Chest radiograph (three views)
Abdominal ultrasound
Bone marrow aspirate
Regional lymph node aspirate or biopsy
Other
Test results #1
Test results #2
Test results #3
Test results #4
Test results #5
Test results #6
Please list all previous health concerns
Current medications/supplements/over-the-counter drugs
Dose/frequency of current medications/supplements
Previous surgeries (non-tumour related) and date(s) of surgery
Additional Patient Information
Does your patient have any allergies?
Does your patient have any metal implants (if being referred for radiation)? Yes
No
Unknown
If yes, please describe implant location
Current diet (amount/frequency of meals)
Special concerns and/or considerations