Patient Referral Form
A referral form for each patient should be completed 48 hours prior to their scheduled exam date.
Referring Veterinary Clinic
*
Please Select
All Friends Animal Hospital
Colchester Veterinary Health Center
Companion Veterinary Health Center
Norwichtown Veterinary Hospital
Pieper-Olson Veterinary Hospital
Pomfret Small Animal Clinic
Quinebaug Valley Veterinary Hospital
Salem Valley Veterinary Hospital
VCA Plainfield Animal Hospital
Vogel Veterinary Emergency and Specialty
If your clinic is not listed, please email Kane Veterinary Imaging
Email of Submitter
*
example@example.com
Appointment Schedule Date
*
-
Year
-
Month
Day
Date
Pet's First Name, Client's Last Name
*
First Name
Last Name
Medical Record Number
*
Is this a new patient of Kane Veterinary Imaging?
*
New patient
Existing patient
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Pet DOB
*
-
Year
-
Month
Day
Date
Age
*
Weight (kgs)
*
Species
*
Please Select
Canine
Feline
Other
If you selected "Other" for species, please specify below
Breed
*
Gender (select all that apply)
*
Male
Female
Spayed
Neutered
Intact
Current Medications (drug, dose, route, frequency; for example "Pimobendan 5 mg PO q12h"). Write "N/A" if no medications
*
Current Pet Diet (if known)
Is the pet's diet grain-free?
*
Yes
No
Unknown
Reason for Referral
*
Is an anesthetic recommendation required?
*
Yes
No
Known co-morbidities (e.g., renal failure, collapsing trachea, etc.)
Clinical signs of heart disease (select all that apply)
*
None
Coughing
Exercise intolerance / lethargy
Dyspnea (difficulty breathing)
Tachypnea (rapid breathing)
Syncope (collapsing / fainting)
Unknown
Recent diagnostics performed (select all that apply)
*
None
Thoracic radiographs
CBC
Chemistry
NTproBNP
Thyroid testing
Unknown
Other
If you selected "Other" for diagnostics, please specify below
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Weight (kgs)
*
Reason for Referral
*
List any changes to current Medications (drug, dose, route, frequency; for example "Pimobendan 5 mg PO q12h"). Write N/A if no changes since last exam
List any changes in clinical signs. Write N/A if no changes since last exam
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