Oncology Referral Form

*Indicates required fields

If the attachments surpass the maximum 50MB file size, please email the patient’s records and imaging directly to oncology@capcityvet.com.

Reason for Referral/Primary Complaint *

Referring Veterinarian Practice *

Client Name *

First

Last

Client Primary Phone Number *

Client Primary Email *

Client's Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Alternate Contact Info (Name, Email, Phone number)

Patient's Name *

Are there any specific details or information our Medical Oncology team should be aware of?

0 of 5000 max characters

Please upload any medical records and relevant diagnostics: *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please make sure your file name does not include any special characters ($&^* etc.) as this can corrupt the file submission.