Veterinarian Referral Form

Thank you for your referral

We promise to take the very best care of your client and your patient.

Choose to either fill out the form below and submit online OR download and print the PDF version, fill it out, and fax to us at (508) 465-3354.

Owner Information

Owner Name *

Phone Number *

Email Address *

City

Patient Information

Patient Name *

Species *

Breed

Age

Gender

Medical Information

History

Please tell us about any prior cancer diagnoses and treatments or other relevant medical history.

Current Diagnosis

Brain Tumor
Carcinoma
Hemangiosarcoma
Lymphoma
Mast Cell Tumor
Melanoma
Nasal Tumor
Osteosarcoma
Prostatic/Transitional Cell Carcinoma
Soft Tissue Sarcoma
Other

If Other:

Tests Run

Please fax all current lab work, results, or other relevant information to: 508-465-3354 or email it to oncology@vcsnewengland.com. For digital radiographs, preferably Dicom images, please send with the owner.

Please check any tests you have already run on this patient.

Abdominal Ultrasound
CBC/ Chemistry/ Urinalysis
CT/MRI
Cytology
Histopathology
Thoracic Radiographs
Additional Radiographs
Bone Marrow
Flow Cytometry
PARR/PCR
Other

If Other:

Treatment Information

List current treatment and medications.

Please share any comments or instructions about this patient or current treatment plan.

Referring Vet Information

Doctor Name

Veterinary Hospital

Phone Number

Fax

Email Address

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Serving the south shore of Massachusetts, Cape Cod, and the Islands.

Call 508-276-0836 for an appointment.