Referral DVMs

Thank you for considering Blackford Veterinary Surgery Referral for your patients’ surgical needs. Please find the online referral form below. You may also download the referral form, and fax it to our office at 865-531-7149. Please be sure to include the medical records of the patient, as well as any radiographs that may have been taken.

Orthopedic Referrals

All referrals regarding *fractures* must be accompanied by radiographs prior to us scheduling the patient. This allows us to ensure we have the proper hardware required for surgical repair.

Soft Tissue Referrals

All referrals regarding *masses* (skin/muscle/subcutaneous) must be accompanied by a cytology/biopsy diagnosis, thoracic radiographs (3 view), and bloodwork (CBC, chemistry panel, UA) before we can schedule an appointment for the patient. This will allow us to understand the urgency of the case and whether additional staging (abdominal ultrasound +/- aspirates) is needed prior to surgical evaluation. (Ex. Patients with anal sac tumors require abdominal ultrasound to assess sublumbar lymph nodes vs. patients being referred for mast cell tumors should have abdominal ultrasounds with liver/spleen aspirates to evaluate metastasis.). It delays patient care and delays surgery if appropriate staging is not done in advance.

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Referring Hospital(Required)

Referring Veterinarian(Required)

First Last

Clinic Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Clinic Phone Number(Required)

Clinic Fax(Required)

Clinic Email(Required)

Client Name(Required)

First Last

Client Phone(Required)

Client Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Client Email(Required)

Patient Information

Patient Name(Required)

Species(Required)

Breed(Required)

DOB / Age(Required)

Sex(Required)

Is the animal:(Required)

Altered

Unaltered

Color(Required)

Weight (lbs)(Required)

Temperament(Required)

Reason for Referral, Special Requests, and/or Current Medications(Required)

Please send/attach ALL of the information listed below that pertains to the injury/referral.

Upload bloodwork:

Max. file size: 64 MB.

Bloodwork performed in the last 6 months?(Required)

Yes

No

*Bloodwork is REQUIRED at our clinic for pets over the age of 7 years, or if they have underlying health conditions or concerns.

Were X-rays Performed?(Required)

Yes

No

*If yes, please send all x-rays to info@blackfordvetsurgery.com

Medical Records

Max. file size: 64 MB.

Medical records attached?(Required)

Yes

No

Additional Comments

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