Angell Oncology Referral Form

The Angell Oncology team thanks you for your referral. While we certainly value your time, we would greatly appreciate your taking a moment to complete this form. The information that you provide will give us a good start on providing your client and patient with our best service. Please feel free to fill out electronically or by hand and then email or fax back to Angell.

If you prefer, in lieu of filling this form out line by line, a case summary that includes the information below would also be welcomed. If you feel that a phone call or email might be an easier option, please feel free to contact us directly - our contact information is listed below.

(1) Please provide us with some information on your clinic:

Referring Veterinarian

*

Name:

Title	First Required	Last Required

*

Email: Required

*

Phone Number: Required

*

Question - Required - Clinic Name and Address:

(Maximum response 255 chars, approx. 5 rows of text)

(2) Please provide us with some information on the patient you are referring:

*

Question - Required - Patient's Name:

Question - Not Required - Species/Breed:

Question - Not Required - Age:

Question - Not Required - Sex (inc. neutering status):

Question - Not Required - Weight:

Question - Not Required - Pre-existing Medical Conditions:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Current Medications and dosages:

(Maximum response 255 chars, approx. 5 rows of text)

*

Question - Required - Is this patient being referred for radiation oncology?

Yes

No

Unsure

(3) Please provide us with some information on the patient's cancer diagnosis:

*

Question - Required - Oncologic Diagnosis/Problem for which pet is being referred:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Location

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Diagnostic Tests Performed/Date Performed

**Was immunohistochemistry (IHC) recommended by pathologist? If so, please submit as soon as possible as turnaround times are generally 2 weeks.

Question - Not Required - Pending Tests

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Any Treatments Started

(Maximum response 255 chars, approx. 5 rows of text)

(4) Please provide us with some information on the client:

*

Question - Required - Owner's Name:

*

Question - Required - Owner Phone Number:

*

Question - Required - Is the owner expecting a call from us to schedule?

(5) Please provide us with any additional pertinent patient or client information:

Question - Not Required - Additional Comments:

Please fax or email medical records and imaging to the contact information below. If you cannot send imaging, please provide the owner with images on a CD to bring to their appointment.

Thank you for your referral. A referral summary letter will be sent following your patient’s appointment.

Sincerely,

Staff Medical Oncologists: Dr. J. Lee Talbott
Staff Radiation Oncologists: Dr. Jillian Walz and Dr. Kristine Burgess

	Angell Oncology Department
PHONE: (617) 541-5136	FAX: (617) 989-1668	EMAIL: oncology@angell.org