Veterinarian Referral Form "*" indicates required fields Referring Veterinarian* First Name Last Name Veterinarian Email* Veterinarian Phone*Are You A Primary Care Or Specialist Veterinarian?* Primary Care Specialist What Is Your Specialty Area?--None--AnesthesiaAvian & ExoticsCardiologyDentistryDermatologyEmergency & Critical CareInternal MedicineMedical OncologyNeurologyOphthalmologyRadiation OncologyRadilologySurgeryOtherPractice Name* Practice Location State / Province / Region ZIP / Postal Code Client Name* First Last Pet Name* Preferred PetCure Oncology Office?*Clifton, New JerseyHouston, TexasJacksonville, FloridaMilwaukee, WisconsinPhoenix, ArizonaPittsburgh, PennsylvaniaRobbinsville, New JerseySan Jose, CaliforniaNo Preference Referral Type?* CT Internal Medicine (Dr. Larry Kantrowitz, DVM DACVIM (SAIM)) Medical Oncology Radiation Oncology Not Sure *For Radiology (Dr. Kyle Francis, DVM, MS, DACVR), please call PetCure Oncology in Clifton, NJ at (973) 772-9902.Reason For Consult?* Consult & Testing Ultrasound ONLY Would you prefer our PetCure Representative call you back to discuss the case or reach out to your client directly?* Call Me Back To Discuss Case Reach Out to Client Directly Client InformationClient Email Client Phone (Primary)*Client Phone (Secondary)Client Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryUnited StatesCanadaMexicoOtherPet InformationSignalmentSpeciesBreedSexAge Add RemovePertinent History*Diagnostics Performed?*Medications (Dosage/Duration/Response)Medications / TreatmentsPlease send all medical records, including lab results and imaging reports, as well as any radiographs. For Ultrasound appointments: Patients must be clinically stable patient must not need sedation (Gabapentin, Trazadone, etc. prior to appointment is fine and encouraged) Client will not be present nor speak with ultrasonographer After the exam, we will call your office with the findings for you to review with your client Attach Medical RecordsFile sizes of up to 100MB can be submitted through this form. If your file is larger in size, we recommend sending it to our petcure.records@thrivepet.com email address.Accepted file types: gif, jpg, jpeg, png, mov, pdf, zip, Max. file size: 100 MB.Clinical HistoryAnatomical Region(s) To Scan*Biopsy or FNA (if possible) Yes No Service Requested/Goal Of Study?
