Small Animal Referral

★ = required

Have you called the VMC about this referral or to consult on this case? ★

Yes

You must select if you have or have not contacted the VMC on this case.

VMC Pre-Admit Number:

Is this a second opinion?

Yes

Date Last Seen:

Referrer Information

DVM: ★

Please provide the referring DVM's name.

Clinic/Hospital: ★

Please enter the referring clinic/hospital.

Street Address: ★

City: ★

Please provide the referring clinic/hospital's city.

State/Province: ★

Please provide the referring clinic/hospital's state.

Zip Code: ★

Please provide the referring clinic/hospital's zip code.

Phone Number: ★

Please provide the referring clinic/hospital's phone number.

Fax Number:

Email Address:

Client Information

First Name: ★

Please provide the client's first name.

Last Name: ★

Please provide the client's last name.

Street Address: ★

Please provide the client's street address.

City: ★

Please provide the client's city.

State/Province: ★

Please provide the referring client's state.

Zip Code: ★

Please provide the client's zip code.

Email Address:

Primary Contact Number: ★

Please provide the client's primary contact number.

Secondary Contact Number:

Patient Information

Patient Name: ★

Please provide the patient's name.

Species: ★

Please select the patient's species.

Breed: ★

Please provide the patient's breed.

Sex: ★

Please select the patient's sex.

Date of Birth: ★

Please provide the patient's date of birth.

Color:

Weight: ★

Please provide the patient's weight and units.

Visit Timeframe ★

Emergency

- Patient needs an emergency appointment.
- Please call the VMC immediately at: 612-626-8387 to discuss options.

Urgent

- Patient needs to be seen within 1-2 weeks.

Stable

- Patient is stable and safe to be seen in greater than 1-2 weeks.

Chronic

- Patient is being referred for a chronic issue and can wait more than 2 weeks.

Please select the timeframe you believe most accurately applies for this referral.

Visit Information

To best treat your patient, please provide detailed information.

Primary Medical Concern(s) for this Referral: ★

Please provide the primary medical concern(s) for this referral.

Owner/Referring DVM Expectations for this Case: ★

Please provide the owner/referring DVM expectations for this case.

Medical History or Master Problem List Related to Referral: ★

Please provide the medical history or master problem list related to this referral.

Medication and Therapeutic History (please provide dates, medication dosages, and response):

Are there any specific instructions that can help us meet the unique needs of this client or patient? ★

Please include any special handling instructions for the patient.

Please provide any special instructions that can help us meet the unique needs of this client or patient.

Dental & Oral Surgery Specific Information

Does this patient have a known or suspected oral tumor or jaw fracture?

Yes

Does this patient have a tooth fracture?

Yes

Which Tooth is Fractured:

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When did the fracture occur (if known)?

Is this patient's pain currently controlled with pain medication and/or antibiotics?

Yes

Does this patient have any oral lesions?

Yes

Has this patient had an anesthetized dental procedure performed within the last 6 months? If so please list the date and pertinent findings. Please send all medical records associated with this patient to vmc@umn.edu.

Please list the date of the last conscious oral exam and pertinent findings if different from above or if an anesthetized procedure was not performed.

Were dental radiographs, skull cone beam CT or skull conventional CT performed? If so please send all images and associated imaging reports to vetpacs@umn.edu.

Oncology Specific Information

How was your diagnosis obtained?

Please list how your diagnosis was obtained.

Has staging been done?

Yes

How is the patient doing clinically?

Please list how the patient is doing clinically.

Have you done a consultation with an Oncologist?

Yes

If surgical, should the patient see our Surgery service before Oncology?

Yes

Nutrition Specific Information

Is this patient experiencing weight loss?

Yes

Is the patient eating?

Yes

Is this a new diagnosis or is this a progressing disease?

New Diagnosis

Progressing Disease

Rehabilitation Specific Information

Animals referred to rehabilitation are not assessed by a veterinarian unless requested. If this is requested, please refer to the appropriate service (i.e. orthopedic or neurology service). If authorizing rehabilitation without an additional exam by a veterinarian, please choose from the treatments below to approve use in this patient:

All listed therapies are authorized

OR choose individual exercises:

Underwater treadmill with or without incline

Land treadmill

Land exercises

Joint range of motion exercises

Therapeutic ultrasound

Therapeutic laser

Shockwave

Please select which therapies are authorized.

Special requests or specific exercise restrictions:

Dermatology Specific Information

A detailed dermatological history form will be sent to you. Completing this additional form allows us to provide the best care possible to your patient.

Imaging

Has imaging been completed on this patient?

Yes

Are imaging links included in the patient record?

Yes

When possible please send us the original DICOM files. DICOM files are large files that contain important information about the patient, image and machine; allowing us to make accurate measurements and alter the contrast/denstiy of an image. All modern x-ray machines allow you to export DICOM files.

Pursuant of Minnesota Rules Part 3100.9600 subpart 14, please make sure that all radiology images contain the patient first and last name and the date they were taken. When you are sending non-DICOM images (such as JPEG, BMP, TIFF, etc that you have exported from your system), please make sure each filename contains this information. Failure to include this information could result in us needing to retake images.

Please indicate what imaging has been completed. Imaging should be uploaded with this referral, emailed, sent to our DICOM server, or sent in with the owner.

Radiographs

CT / MRI

Ultrasound

Other

Please upload pertinent imaging files.

You can upload up to 10 Imaging files.

Date Taken: ★

Email Address (For Imaging): vetpacs@umn.edu

Dicom Server:
IP Address/Hostname: 134.84.120.106
AE Title: D6541
Port Number: 4006

Additional Diagnostic Procedures

Have any additional diagnostic procedures been completed on this patient?

Yes

Please list any additional diagnostic procedures that have been completed.