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Oncology Patient Referral Form

Date*
MM slash DD slash YYYY
Referring Veterinarian:*
Hospital:*
Phone:*
Fax:*
Email:*
Client Information:
Client:*
First Last
Phone:*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Patient Information:
Name:*
Species:*
Age:*
Breed:*
Appointment Request:*
- Ill Patient/Time Sensitive
- First Available
Neoplasia:*
- Peripheral Lymphadenopathy
- Cutaneous/SQ Mass
- Intra-Thoracic Mass
- Oral Mass
- Splenic Mass
- Intra-Abdominal Mass
- Anal Sac Mass
- Bladder Mass
- Other
Other:
Diagnostics Performed:*
- Bloodwork
- Biopsy
- Thoracic Radiographs
- Limbs Radiographs
- Abdominal Ultrasound
- Thoracic Ultrasound
- Other
Other:
Treatments:*
- None
- NSAIDs
- Antiemetics
- Corticosteroids
- Pain medications
- Other
Other:
Diagnosis if known:
- Lymphoma
- AGASACA
- Mast Cell
- Osteosarcoma
- Melanoma
- Mammary Carcinoma
- Cutaneous Lymphoma
- Urothelial Carcinoma
- Hemangiosarcoma
- Soft Tissue Sarcoma
- Histiocytic Sarcoma
- Other
Is the diagnosis confirmed or suspected/tentative?
- Confirmed
- Suspected/Tentative
Concerns:

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Portland, ME 2255 Congress Street 207-878-3121

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