312-736-7757 VDCchicago@VDC.vet

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Veterinary Diagnostic Centers

Comprehensive Internal Medicine Form

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Please click on the appropriate location.

Mokena, IL
Chicago, IL
Crown Point, IN

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Please indicate who you would like to have discuss with owner: *

Veterinary Diagnostic Centers
Referring Veterinarian

We are a Fear Free facility. We suggest that an oral sedative be prescribed but this is not mandatory. If you and the family believe this is not necessary we can do without. For suggested protocol please refer to our Referring Vets dropdown. Please indicate whether an oral sedative will be prescribed. (copy) *

We have only needed to administer an injectable sedative to less than 1.0% of our patients. Please indicate if you believe, due to aggression or other behavioral concerns, that this will need to be done with this patient. *

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

The internal medicine specialists that will completing the consultation require updated bloodwork within 4 weeks. If this is not provided in the records received we will need to collect and submit. If you have any reason that you do not want us to collect and submit please note here.

Please upload medical records, labs, images, and previous referral reports

Click or drag files to this area to upload. You can upload up to 5 files.

Client Name

First

Last

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

Please indicate who you would like to have discuss with owner: *

Veterinary Diagnostic Centers
Referring Veterinarian

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

If we believe an FNA of an intra-abdominal structure would be safe and worthwhile do we have your consent to perform and submit? We will seek the consent of the pet owner as well, discussing risks and costs with them.

Please upload medical records, labs, images, and previous referral reports

Click or drag files to this area to upload. You can upload up to 5 files.

Client Name

First

Last

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

Message

Please indicate who you would like to have discuss with owner: *

Veterinary Diagnostic Centers
Referring Veterinarian

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

Please upload medical records, labs, images, and previous referral reports

Click or drag files to this area to upload. You can upload up to 5 files.

Client Name

First

Last

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

Message

Veterinary Diagnostic Centers in Chicago, IL

Veterinary Diagnostic Centers is here when your veterinarian needs additional diagnostic expertise for your pet’s care. Your doctor has the flexibility to recommend just an ultrasound report or, for more involved cases, a full remote specialist consultation that we will coordinate.

Referral Forms