Refer a Case

Referring Veterinary Surgeon's Information
Vet's Name*
First Last
Vet Clinic and Branch*
Vet Clinic and Branch Patient is Registered (if different from above).
Clinic Telephone Number
Email
Date
DD slash MM slash YYYY
Patient/Pet Information
Animal's Name*
Pet's Name Owner's Surname
Species*
Please specify species
Breed*
Weight in Kgs*
Sex/Neutered*
Age*
Nature of Problem/Reason for VVS Consultation
Which Specialist discipline do you require?*
Notes
Which type of VVS service do you require? E.g. Specialist advice call, Live-guided consultation, Specialist written case report
Please enter the code for the VVS service you require (if known)
Notes
Please describe the pet's condition and provide a brief summary of the relevant history (NB: This history summary needs to be provided in addition to attaching the patient records).*
Please list current medications:
Any other relevant information:
For Live-Guided Procedures only: Are you able to place an IV catheter without prior sedation in this patient? Is the patient nervous and/or aggressive in the veterinary practice?
Sedation support will be offered if required.
Is this case an emergency, urgent or routine request?
Patient Records and Relevant Diagnostic Test Results
Please upload a copy of the patient records including blood tests, urinalysis, cytology or histopathology results and radiographs. Select Yes or No to indicate what has been submitted in addition to this form. You can also email these to info@vvs.vet. X-ray/Imaging submission is limited to 8 files. Maximum file size is 500MB. Larger files please email separately to info@vvs.vet. FOR ALL RADIOLOGY REPORTS please submit DICOM files for radiology review. DICOM files will need to be sent via your PACS system, WeTransfer, Dropbox or Google drive to info@vvs.vet.
X-Rays / Imaging
Please submit a maximum of 8 files. To submit additional files please contact us directly. Maximum file size is 500MB. Larger files please email separately to info@vvs.vet. FOR ALL RADIOLOGY REPORTS please submit DICOM files for radiology review. DICOM files will need to be sent separately via your PACS system, WeTransfer, Dropbox or Google drive to info@vvs.vet.
X-Ray/Imaging
Drop files here or

Max. file size: 800 MB, Max. files: 8.
Lab Results
Lab Results
Drop files here or

Max. file size: 800 MB.
Patient Records
Please submit relevant case history or a written case summary for advice calls.
Patient Records
Drop files here or

Max. file size: 800 MB.
Getting the Most out of Your VVS Consult
Please tell us what question(s) you would like to answer about this case:*
Please also tell us what you are hoping to achieve from this consult:
Consent

All of the patient information provided is complete to the best of my knowledge and I accept VVS are only able to provide services based on the information provided to them. The primary case responsibility remains with the referring clinician.
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Refer a Case

Referring Veterinary Surgeon's Information

Patient/Pet Information

Nature of Problem/Reason for VVS Consultation

Patient Records and Relevant Diagnostic Test Results

Getting the Most out of Your VVS Consult