Which service are you requesting this be forwarded to? (For urgent transfers, please call the hospital directly.)*

Nephrology

Oncology

Ophthalmology (Currently booking out 4-5 months)

Neurology

Surgery

Internal Medicine

Are you making a referral or requesting a consultation?*

Consultation (Vet to vet conversation regarding case)

Referral (We will call your client to schedule an appointment)

Are you making a referral or requesting a consultation?*

Consultation (Vet to vet conversation regarding case)

Referral (We will call your client to schedule an appointment)

Internal Medicine Current Client Consult & Diagnostic Interpretation Request ($95)

Level of Severity*

1. Urgent (LSA, MCT [rapidly growing], oral masses, osteosarcoma, lymphoblastic leukemia, insulinoma [symptomatic], hemangiosarcoma)

2. Intermediate to Stable (STS, anything larger than a half dollar already, anything ulcerated or rapidly growing, pulmonary masses, insulinoma (asymptomatic), hemangiosarcoma (surgically removed), adrenal tumors, thyroid carcinoma, CLL, apocrine gland adenocarcinoma of the anal sac, lipoma, undiagnosed stable skin masses, canine mammary gland tumor, myxosarcoma)

Do you suspect this patient will need sedation for an ophthalmic exam due to behavior?*

Yes

The purpose of this consultation request is to receive a recommendation of next steps, medications, and diagnostic interpretation for a patient that has previously seen our internal medicine service but has decided to continue care with their primary care veterinarian as opposed to returning to our hospital for a recheck. The cost is $90 which will be invoiced and sent to the referring veterinary clinic. Your clinic may choose to invoice your client however you deem appropriate. We commit to responding within 24 business hours (Monday through Thursday, 8am-5pm) by your indicated preferred method of communication. Unfortunately, we are unable to give recommendations directly to the client for diagnostics performed at other hospitals. These recommendations must be made direct to the primary care veterinarian.

Current Patient Information

Pet Name*

MVS patient ID (if available)

Primary Care DVM*

Primary Care Clinic*

Patient’s Current Weight and Date Taken*

Patient’s Current Medications and Dosages*

Please upload recent physical exam and diagnostics

Drop files here or

Accepted file types: jpg, png, pdf, doc, xls, Max. file size: 256 MB, Max. files: 10.

Patient Information

Pet Name*

Age*

Sex*

Male

Female

Altered

Breed*

Weight (Specify lbs or kgs)*

Pet Owner Information

Client Name*

Client Address

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Primary Care Information

Primary Care DVM*

Primary Care Clinic*

Contact Phone

Contact Email

Contact preference*

Phone

Any information regarding your availability in the next three days?*

Referring Veterinarian Information

Doctor's Name*

Clinic*

Clinic Phone*

Clinic Fax

Clinic Email*

Preferred Method of Communication*

Phone

Fax

All

Additional Information

If you are submitting a referral for Internal Medicine, it is critical we receive the patient's full medical record including all exams, lab work and imagining for the entirety of the animal's life. If you have issues attaching here, please email them to mvs@mvsvets.com. Thanks!

Reason for Referral*

(The rest of the questions can be a short summary if medical records are attached)

Patient History

Physical Exam Findings

Previous Diagnostics

Medication/Response

Please upload all medical records including labs and images.

Drop files here or

Accepted file types: jpg, png, pdf, doc, xls, Max. file size: 256 MB, Max. files: 10.

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Phone

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

Request a Consultation / Make a Referral

This form is only to be used by veterinarians and their teams. If you are a potential client, please call the clinic to schedule an appointment.

Current Patient Information

Patient Information

Pet Owner Information

Primary Care Information

Referring Veterinarian Information

Additional Information