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Roam Veterinary Surgery
Referral Request Form (Ortho)
Referral Request Form (Ortho)
Please fill out Referral Request Form (Ortho) as completely and accurately as possible.
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Referring Veterinarian
*
Referring Hospital:
*
Referring Email Address:
*
Pet’s name:
*
Client’s name:
*
Pet’s DOB:
*
Breed
*
Weight(kg):
*
Sex:
*
Male
Female
Altered
*
Yes
No
Diagnosis:
*
Limb Affected (Side):
Right
Left
Radiographs performed?
*
YES
NO
Radiology review performed?
*
YES
NO
Thoracic radiographs performed? (required for all trauma causes)
*
YES
NO
Bloodwork performed? (required within 1-2 weeks for all surgeries)
*
YES
NO
**Please email all bloodwork, radiographs, and radiology reports to
[email protected]
.
Skin checked for pyoderma?
*
YES
NO
Please list all medications:
*
Any co-morbidities? (ex: endocrinopathies, renal/hepatic disease)
*
Any other relevant information to patient/case?
For fracture referrals only:
Can patient ambulate on unaffected limbs?
YES
NO
Is there pain sensation in toes of affected limb?
YES
NO
Is there voluntary motor in affected limb?
YES
NO
Can patient urinate?
YES
NO
Are there open wounds over affected limb?
YES
NO
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