VVS PATIENT REFERRAL FORM

1
Have you referred a case to VVS previously?* This field is required.This can be for a different patient
YESNO
2
Referring Veterinary Surgeon's Information:* This field is required.
First Name
Last Name:
3
To best tailor this VVS consult to you, please highlight if you have relevant clinical interest/experience in this area?E.g. hold a certificate or have undertaken further training
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Ok
Ok
4
Referring Veterinary Practice:* This field is required.
Practice Name:
Contact No.:
5
Contact Email Address: * This field is required.Please specify the email you would prefer us to contact you on.
example@example.com
6
Referring Veterinary Surgeon's Information:* This field is required.Please complete ALL the fields below.
7
Patient Details:* This field is required.Please complete ALL the fields below.
8
Have you already booked a VVS appointment for this patient?* This field is required.Tick yes if completing as part of an online booking. If no, we will be in contact with our availabilty.
YESNO
9
Please select the discipline you require:* This field is required.Please scroll down for all options.
Please Select
Please Select
Cardiology
Diagnostic Imaging inc Internal Medicine
Internal Medicine Only
Oncology
Dermatology
Neurology
Ophthalmology
Anaesthesia
Dentistry
Exotics
10
Please select the service you require:* This field is required.Please click on the following links for HOLTER or RADIOLOGY requests.
Please Select
Please Select
VVS Live Guided Work Up
Specialist Advice Call
Specialist Written Report
Specialist ECG Report (Cardiology only)
Specialist Written Report including review of echo images (Cardiology only)
Specialist and Owner Teleconsultation
11
Please select the service you require:* This field is required.Please click on the following links for HOLTER or RADIOLOGY requests.
Please Select
Please Select
Specialist Advice Call
Specialist Case Specific Written Report/Protocol
Specialist and Owner Teleconsultation
12
Urgency of appointment required:* This field is required.Please note this does not affect pricing.
13
Is the patient stable?* This field is required.
14
Please provide a brief summary of the relevant history, and list any current medications:* This field is required.
15
What date is the patient history relevant from, or when did the patient first present with this condition?* This field is required.If exact date is not known please select an approximate.
Date
Day
Month
Year
16
Please list any relevant and/or ongoing previous diagnosis:* This field is required.Please put N/A if not relevant.
17
Has this patient displayed any of these within the past 24 hours?* This field is required.
Vomiting/Regurgitation
Lethargy
Collapse
Respiratory distress/oxygen dependency
Arrhythmia
Pyrexia
Hypovolemia
Moderate/severe anaemia
Other (provide details when requested)
None of the above
18
Has this patient been admitted for hospitalisation?* This field is required.
YESNO
19
Does the patient have an IV placed/will tolerate IV placement?* This field is required.Please note an IV & consent for sedation is required for all VVS live-guided ultrasound, even if sedation is not required.
YESNO
20
Patient File UploadPlease upload the patient's clinical history, lab results/imaging etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
Additional notes regarding this patient (inc. clinical symptoms if required):Please put N/A if nothing additional to add.
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Ok
22
Are you planning on taking FNAs for this patient?* This field is required.Please note you must complete the VVS FNA CPD before we are able to support with live-guided FNAs.
YESNO
23
Would you appreciate a pre-work up stabilisation advice call for this patient?* This field is required.
YESNO
24
What question(s) you would like to answered about this case:* This field is required.
25
Consent* This field is required.Please read and confirm
All of the patient information provided is complete to the best of my knowledge and I accept VVS are only able to provide services based on the information provided to them. The primary case responsibility remains with the referring clinician.
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Abdominal ultrasound is a great first imaging modality in many patients, however, it has been shown to be less sensitive than abdominal CT in some patients weighing > 25 kg. In a study, abdominal CT found more clinically and equivocally relevant changes than abdominal ultrasound.

Based on our clinical experience, abdominal ultrasound can still be extremely useful in dogs greater than this weight, depending on the clinical disease/pathology suspected. However, the owner must be made aware that although ultrasound may find significant abnormalities that would explain the patient’s clinical signs, there is a risk of missing other clinically relevant findings and therefore an abdominal CT may still be required as the next step.
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