Veterinarian Referral Form For Portal Users

Referring Veterinarian*

First Name Last Name

Veterinarian Direct Email*

Veterinarian Phone*

Are You A Primary Care Or Specialist Veterinarian?*

Primary Care

Specialist

What Is Your Specialty Area?

Practice Name*

Practice Location

State / Province / Region ZIP / Postal Code

Preferred PetCure Oncology Office?*

Client Name*

First Last

Pet Name*

Referral Type?*

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 Information

Client Email

Client Phone (Primary)*

Client Phone (Secondary)

Client Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Country

Pet Information

Signalment

Species

Breed

Sex

Age

Pertinent History*

Diagnostics Performed?*

Medications (Dosage/Duration/Response)

Medications / Treatments

Please 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 Records

File 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.

Drop files here or

Accepted file types: gif, jpg, jpeg, png, mov, pdf, zip, Max. file size: 100 MB.

Clinical History

Anatomical Region(s) To Scan*

Biopsy or FNA (if possible)

Yes

Service Requested/Goal Of Study?

Portal Veterinarian Referral Form

Client Information

Pet Information

Clinical History