Referral form

Which service are you referring to? Please tick the correct box.

X

ANIMAL
EMERGENCY CARE

X

PERTH ANIMAL
SURGERY

X

ANIMAL
DERMATOLOGY CLINIC

X

VETERINARY
IMAGING CENTRE

X

PERTH VETERINARY
ONCOLOGY

X

VETERINARY MEDICINE
SPECIALISTS

General Information

Preferred method of communication
X
Email
X
Fax
X
Phone

Sex
X
Male
X
Female

De-sexed
X
Yes
X
No

Additional History: please provide the following

X
Attach Browse
X
Fax or Email
X
None

Lab results

X
Attach Browse
X
Fax or Email
X
None

Radiographs

X
Attach Browse
X
Fax or Email
X
Sent with client
X
None

Outpatient Imaging Services

Ultrasound

X
Abdomen
X
Echocardiogram
X
Both
X
Other

*Fine needle aspirates may be performed during routine examinations. Please call VIC to discuss biopsies

Radiology

X
Thorax
X
Abdomen


X
Musculo-skeletal

Interpretation/2nd Opinion

X
Verbal
X
Written
X
Film
X
CD
X
Emailed

Advanced Imaging

Please call VIC prior to booking.

X
CT
X
MRI

For Animal Emergency Referrals, please fill in the Animal Emergency Referral form here