Patient Referral Form
A referral form for each patient should be completed 48 hours prior to their scheduled exam date.
Today's Date
/
Month
/
Day
Year
Date
Scheduled Exam Date
*
/
Month
/
Day
Year
Date Picker Icon
Referring Veterinary Clinic
*
Please Select
All Friends Animal Hospital
Colchester Veterinary Hospital
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
Pet's First Name, Client's Last Name
*
First Name
Last Name
Patient ID
*
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
Weight (kgs)
*
Is this a new patient of Kane Veterinary Imaging?
*
New patient
Existing patient
Back
Next
Save
Pet DOB
*
-
Month
-
Day
Year
Date Picker Icon
Age
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
Back
Next
Save
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
Back
Next
Save
Upload Medical Records
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Save
Submit
Should be Empty: