Records Submission Form - Colorado Animal Specialty & Emergency

Referral & Records Submission Form

Please fill in the form below and click the Submit button.

fields marked with * are required and must be included in order to submit the form.

Submission Type(Required)

PLEASE CALL FIRST in addition to sending records and client information.

Please also call the main number.

The Oncology team at The Pet Cancer Center thanks you for your referral. While we certainly value your time, we would greatly appreciate your taking a moment to complete this form. The information that you provide will give us a good start on providing your client and patient with our best service. Please feel free to fill out electronically or by hand and then email or fax back to CASE.

If you prefer, in lieu of filling this form out line by line, a case summary that includes the information below would also be welcomed. If you feel that a phone call or email might be an easier option, please feel free to contact us directly – our contact information is listed below.

(1) Please provide us with some information on your clinic:

Referring Veterinarian(Required)

Title First Last

Email(Required)

Phone Number(Required)

Clinic Name and Address(Required)

(2) Please provide us with some information on the patient you are referring:

Patient's Name(Required)

Patient’s First Name Patient’s Last Name

Species/Breed

Age

Sex (including neutering status)

Weight in kilograms:

Pre-existing Medical Conditions

Current Medications and Dosages

*Is this patient being referred for radiation oncology?

Yes

Unsure

(3) Please provide us with some information on the patient’s cancer diagnosis:

Oncologic Diagnosis/Problem for which pet is being referred:(Required)

Location:

Diagnostic Tests Performed/Date Performed:

Was immunohistochemistry (IHC) recommended by pathologist? If so, please submit as soon as possible. Turnaround times are generally 2 weeks.(Required)

Please upload any pathology reports (with special stains/IHC, if indicated):

Max. file size: 300 MB.

Please upload any imaging reports (if radiologist reviewed ultrasound or radiographs):

Max. file size: 300 MB.

Any Treatments Started:

(4) Please provide us with some information on the client:

Owner's Name:(Required)

Owner Phone Number:(Required)

Is the owner expecting a call from us to schedule?(Required)

(5) Please provide us with any additional pertinent patient or client information:

Additional Comments:

Please fax or email medical records and imaging to the contact information below. If you cannot send imaging, please provide the owner with images on a CD to bring to their appointment.

Thank you for your referral. A referral summary letter will be sent following your patient’s appointment.

Sincerely,

Medical Oncologists: Dr. Brooke Fowler and Dr. Annie Galloway

Radiation Oncologist: Dr. Lyndsay Kubicek Staff

Surgical Oncologist: Dr. Cassandra Prpich

Referring Hospital(Required)

Referring Doctor(Required)

Referring Doctor Phone(Required)

Referring Doctor Email(Required)

Client Name(Required)

Client Phone

Patient Name(Required)

Breed(Required)

Please select the primary breed mix.

Canine or Feline(Required)

Sex(Required)

Age

History

Lab Results

Additional Pertinent Information

Depending on the amount and size of the files you select, the form could take several minutes to submit.
Maximum total upload size is 50MB

Attach File(s)

Drop files here or

Accepted file types: pdf, tif, jpg, Max. file size: 50 MB, Max. files: 10.

How many files are attached?

File

Max. file size: 300 MB.

Comments

This field is for validation purposes and should be left unchanged.