Referral Request Updated 2024 SCVIM

Do you strongly suspect or have confirmed it is CANCER?*

YesNo

Do you have confirmed CYTOLOGY or HISTOPATHOLOGY?*

YesNo

Is it LYMPHOMA?*

YesNo, it is another form of cancer.

What is the diagnosis?*

For LYMPHOMA, we hold specific appointments with an ONCOLOGIST to allow treatment to start as quickly as possible. Do you accept this recommendation?*

Agree to LYMPHOMA CONSULT with ONCOLOGISTAgree to FIRST AVAILABLE (including URGENT CONSULT with our Support Veterinarian (Non-specialist))

What clinical concerns do you have?*

Physical exam changeRadiograph changeLabwork changeOther

We recommend an appointment with an ONCOLOGIST. Do you accept this recommendation?*

Agree to SUSPECTED CANCER CONSULT with ONCOLOGISTAgree to FIRST AVAILABLE (including URGENT CONSULT with our Support Veterinarian (Non-specialist))

What is the body system of primary concern?*

What endocrine disease is suspected?*

Primary HyperparathyroidismAdrenal DiseaseDiabetesOther

What form of upper airway disease is suspected?*

Nasal DiseaseLaryngeal Paralysis in a large breed dogBrachycephalic SyndromeOther

For nasal disease or undefined disease, we recommend a consultation with an INTERNIST.*

Agree to INTERNIST CONSULTAgree to FIRST AVAILABLE (including URGENT CONSULT with our Support Veterinarian (Non-specialist))

For laryngeal paralysis or brachycephalic syndrome, we recommend a consultation with Mountain View Veterinary Surgery.*

Agree to CONSULT with SURGEONOther

For Primary Hyperparathyroidism, we recommend consultation with an INTERNIST. For some cases, we may be able to treat these with ultrasound-guided alcohol ablation rather than surgery. Small urinary bladder stones may even be able to be removed with urohydropulsion rather than surgery. Do you accept this recommendation?*

Agree to INTERNIST CONSULTAgree to FIRST AVAILABLE (including URGENT CONSULT with our Support Veterinarian (Non-specialist))

SCVIM no longer provides evaluation or care for cardiac disease and pulmonary hypertension. We recommend contacting a cardiologist.*

Stop this form and I will contact a cardiologist.I still request SCVIM care.

We recommend a consultation with an INTERNIST.*

Agree to INTERNIST CONSULTAgree to FIRST AVAILABLE (including URGENT CONSULT with our Support Veterinarian (Non-specialist))

If you have requested an urgent appointment with our support veterinarian, we will let you know soon if we can accommodate this request. If the patient is unstable, please seek care at an emergency clinic. Please honor that we are by appointment only and do not accept walk-ins.

If we are unable to accommodate this appointment within 3 business days, what would you like to do?*

The client should be advised to go to an emergency clinic.If an urgent appointment is not available within 3 businesss days, please schedule with a specialist

Your Guide to Advanced Care for Your Patients