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pagetitle_icon.jpgPetCure Oncology Referral Form

To refer a patient for Stereotactic Radiosurgery (SRS), please fill out the following form.

Patient Information
Gender *
Spayed/Neutered *
Owner Information
Referring Veterinarian Information
Preferred medical record delivery method *
Are you the primary DVM contact if LVS veterinarians have questions regarding this case? *
Other Veterinarian Directly Involved In This Patient's Care
Diagnostics Performed
CBC *
Serum chemistry *
Other laboratory testing (test, date) *
Histopathology *
Cytology *
Thoracic radiographs *
If yes, select all that apply
Other radiographs *
Abdominal ultrasound (date most recent) *
Other ultrasound *
CT scan *
MRI (body part(s) & date) *
Additional Information
This patient is being referred to PetCure at Lakeshore Veterinary Specialists for the following reason *
Please select one *
Please select one *
If additional treatment or diagnostics are determined to be necessary at the time of treatment, please do the following *
Medical Records
Please forward all pertinent medical records, laboratory reports (blood work, histopathology, etc), and radiology/imaging reports. Medical records can be uploaded below or faxed to 414-540-6720 attn: PetCure.
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After uploading files, please wait a few seconds to click on the Submit button. If the button is grayed out, the files are still loading into our database. Thank you.