CUHA Patient Referral Form

Patient Referral and Medical Records
Referral Form Date

MonthDayYear
Date
General Information
Name of Clinic*
Name of Referring Veterinarian
Referring Veterinary Clinic Phone Number*
Please enter a valid phone number.
Referring Veterinary Clinic Email*
example@example.com
Preferred Method of Contact the Referring Clinic

PhoneEmailPhone or Email
Owner Name*

First NameLast Name
Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Email
example@example.com
Owner Phone Number*
Please enter a valid phone number.
Patient Name*
Species*
Breed*
Age
indicate months or years
Sex

Intact FemaleIntact MaleSpayed FemaleNeutered Male
Weight
indicate in kgs or lbs
Select which hospital to refer this patient:*

Companion Animal HospitalEquine and Nemo Farm Animal Hospital

Referral Reason

Companion Animal Hospital
Please select from the options below to communicate which type of referral you are seeking:

Vet to Vet Consult Only: A member of the service will contact the referring veterinarian by phone or email to discuss the case directly.

This information is provided as a public service consistent with the mission of the Cornell University College of Veterinary Medicine. It does not form any element of a veterinarian-client-patient relationship (VCPR) and should not be considered treatment of a patient.

Routine Referral: Schedule Routine appointments will be scheduled as they are available.

Urgent Referral: Urgent appointments will attempt to be scheduled once records are received. If this cannot be facilitated, referral to another facility may be recommended after case review.

Update Patient Record: This option provides Cornell additional documentation for shared patient care.
Please select from the options below:*

Vet to Vet ConsultRoutine ReferralUrgent ReferralUpdate Patient Record
Please select the small animal service to send this patient's updated documentation:*
Please select the small animal service you are requesting:*
Brief Reason for Visit*
Case Synopsis/History: *

Referral Reason

Equine and Nemo Farm Animal Hospital
Please select from the options below to communicate which type of referral you are seeking:

Vet to Vet Consult Only: A member of the service will contact the referring veterinarian by phone or email to discuss the case directly.

This information is provided as a public service consistent with the mission of the Cornell University College of Veterinary Medicine. It does not form any element of a veterinarian-client-patient relationship (VCPR) and should not be considered treatment of a patient.

Routine Referral: Schedule Routine appointments will be scheduled as they are available.

Urgent Referral: Urgent appointments will attempt to be scheduled once records are received. If this cannot be facilitated, referral to another facility may be recommended after case review.

Update Patient Record: This option provides Cornell additional documentation for shared patient care.
Please select from the options below (Large Animal):*

Vet to Vet ConsultRoutine ReferralUrgent ReferralUpdate Patient Record
Please select the large animal service to send this patient's updated documentation:*
Please select the large animal service you are requesting:*
Brief Reason for Visit (Large Animal)*
Case Synopsis/History (Large Animal): *

Cardiology

Dentistry

Dermatology

Emergency

Exotics

Internal Medicine
Is this a referral for RAIT/I-131?

NoYes
Our Internal Medicine Service is currently experiencing a high volume of referrals and at this time can only accept urgent referrals. Because we continue to receive and process new urgent referrals daily, we are unable to guarantee a specific timeframe for when an appointment will become available. All urgent cases will be reviewed by our team and placed on a waitlist, with scheduling prioritized based on medical urgency.

If you'd like to proceed with this referral, we’re happy to place this case on the waitlist with the understanding that wait times may be longer than usual. We truly understand how important timely care is and sincerely appreciate your patience as we do our best to support as many patients as possible.
SAIM-send to Last Page

Neurology

Oncology

Ophthalmology
Are you referring this patient for Cataract?*

YesNo
Ophtho-Send to Last Page

Reproductive Medicine

Sports Medicine

Companion Animal Hospital
What diagnostics have been performed? (check all that apply)

BloodworkRadiographsCTMRIUSOther
Please upload all reports using the File Upload feature at the end of the questionnaire.
SMR- send to Last Page

Imaging

Companion Animal Hospital
Check the appropriate box(es) and attach supporting documentation in the "upload files" area at the bottom of this form.
Select the desired exam below.

Full AbdomenSingle StructureGastrointestinalHepatobiliaryUrogenitalLiver Shunt
*We do not perform echocardiography on an out-patient basis. Please refer to or consult with our Cardiology Service.
Please list any current medications the pet is on:
Important Notes

Out-patient ultrasonography is performed in the Imaging Section. For safety and confidentiality concerns, owners are not permitted in this area at this time.

Cornell Imaging will not sedate patients for this procedure.

Patients who are unable to lie still on their back or side for up to 40 minutes cannot be examined. If sedation is required and the referring veterinarian determines that it is safe, some patients may be sedated prior to the visit.

We will not examine aggressive dogs or fractious cats.

Please have your clients fast the patient 10 hours prior to the appointment. Water and medications are okay to give. If medications require food, please utilize a small amount of food.

We prefer the pet to have a full urinary bladder at the time of the appointment.

Although every attempt will be made to examine the patient at the scheduled time, unexpected delays and emergencies may arise, causing appointments to be delayed.
Imaging - send to Last Page

Anesthesia (Consultation Request)
Please note: The Anesthesiology service reviews cases in the order received and will provide a reply via email on Friday.
Has this patient been seen by Cornell University Hospital for Animals previously?

YesNo
Date Seen at Cornell University Hospital for Animals?
Synopsis/Questions:

Diagnostics Performed:

	YES (include findings below)
Complete blood count
Biochemistry
Imaging
Cariology exam
Other

Please summarize any significant findings for other diagnostic tests:
Upload any relevant files on the next page

Patient Referral Form
Patient Medical Records
Please provide any additional information regarding this case.
Referrals will only be considered with a complete referral form, patient medical records, and radiographs.
Please upload medical records, radiographs, along with any other pertinent documents or records and include a valid Rabies Vaccination Certificate.*

10MB limit
Cancelof
10MB limit error received (check to notify scheduler)
If images are not attached or received and this case is identified as urgent, they will not be reviewed as urgent.

**If trying to send files for Surgery larger than 10 MB collectively or you recieve an error when trying to submit this form due to file size, please send the remainer of the files to CAHSurgery@cornell.edu.
**If trying to send files for Internal Medicince larger than 10 MB collectively or you recieve an error when trying to submit this form due to file size, please send the remainer of the files to SAIM@cornell.edu.
**If trying to send files for Neurology larger than 10 MB collectively or you recieve an error when trying to submit this form due to file size, please send the remainer of the files to Neuroscheduling@cornell.edu.
Urgent requests must be accompanied by photos to be considered urgent.

**If trying to send files Ophthomololgy larger than 10 MB collectively or you recieve an error when trying to submit this form due to file size, please send the remainer of the files to CAHOphtho@cornell.edu.
Form Created XXX
Should be Empty:

	Yes- Include significant findings below	No
Complete Blood Count:
Biochemistry Panel:
Urinalysis:
Thoracic Radiographs:
Abdominal Radiographs/Ultrasound:
Other Radiographs:
Cytology:
Histopathology:
Other:

Patient Referral and Medical Records

General Information

Referral Reason

Referral Reason

Cardiology

Dentistry

Dermatology

Emergency

Exotics

Internal Medicine

Neurology

Oncology

Ophthalmology

Reproductive Medicine

Sports Medicine

Surgery

Imaging

Anesthesia (Consultation Request)

Patient Referral Form

Patient Medical Records