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. 

Please Note: There seems to be a problem submitting the form when using Internet Explorer (IE) so please use another browser until the issue has been addressed.

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
Hospital name
Email address
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)
Detailed patient history, findings and tentative diagnosis (please include dates)
Was the tumour surgically resected prior to referral? Yes
No
Date(s) of previous surgical resection(s)
Tumour size (__cm x __cm x __cm)
Tumour location
Staging Completed Prior to Referral
Please check each test performed and attach the corresponding test results. If you are having difficulties attaching the test result files, please email the files to vmccorrespond@usask.ca.
Test results Tumour biopsy/histopathology
CBC
Blood chemistry
Urinalysis
FeLV/FIV/T4 (feline)
Chest radiograph (three views)
Ultrasound
Fine needle aspirate
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 and frequency of administration
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