Small Animal Referral

 
★ = required
Have you called the VMC about this referral or to consult on this case? ★
You must select if you have or have not contacted the VMC on this case.

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 ★


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

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

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

- 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.

Requested Services ★

In order to expedite services, referrals are reviewed and if indicated will be redirected to the most appropriate available service.

Invalid Feedback

Visit Information

★
Please provide the primary medical concern(s) for this referral.
★
Please provide the owner/referring DVM expectations for this case.
★
Please provide the medical history or master problem list related to this referral.
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.

Cardiology Specific Information

Does this patient have a heart murmur?
Grade of Heart Murmur:
Invalid Feedback
Does this patient have an arrhythmia?
Has an EKG Been Performed?
What was the HR (bpm):
Invalid Feedback
Is the patient experiencing any of the following symptoms?
Invalid Feedback

Dental & Oral Surgery Specific Information

Does this patient have a known or suspected oral tumor or jaw fracture?
Does this patient have a tooth fracture?
Which Tooth is Fractured:
Invalid Feedback
When did the fracture occur (if known)?
Is this patient's pain currently controlled with pain medication and/or antibiotics?
Does this patient have any oral lesions?

Oncology Specific Information

Please list how your diagnosis was obtained.
Has staging been done?
Please list how the patient is doing clinically.
Have you done a consultation with an Oncologist?
If surgical, should the patient see our Surgery service before Oncology?

Nutrition Specific Information

Is this patient experiencing weight loss?
Is the patient eating?
Is this a new diagnosis or is this a progressing disease?

Dermatology Specific Information

Labs & Additional Records

Have labs been performed on this patient?
Please indicate which labs have been completed and when (if possible). Labs should be uploaded with this referral, faxed, or sent in with the owner.
Please upload pertinent lab files.
You can upload up to 10 lab files.
Fax Number (For Labs and Records): 612-624-8779
Email Address (For Labs and Records): vmc@umn.edu

Imaging

Has imaging been completed on this patient?
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.
You can upload up to 10 Imaging files.
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?
Invalid Feedback
 
Please note, on submission of this form a confirmation email will be sent to yourself as well as the client (if email addresses are entered).