Skip to content

Referral Portal

PHONE: 954-527-3111
FAX: 954-653-4644
WEB: animalcancercareclinic.com

Call-In Referral

All Referrals

X/Twitter
This field is for validation purposes and should be left unchanged.
This field is hidden when viewing the form
Region
Looking into auto selecting the Region based on Preferred Location selection.
- South Florida
- Central Florida
This field is hidden when viewing the form
Source
- POR
- WEB
- CIN
This field is hidden when viewing the form
Development
- FUP-1
- FUP-2
- FUP-3
- MUP
- REC-PEN
- REC-COM
- CNF-LM
- CNF-Early
- CNF
This field is hidden when viewing the form
Result
- VIS
- CAN
- NSH
This field is hidden when viewing the form
Active
- Yes
- No
Appt Date
Month
Day
Year
Appt Time

: Hours

Minutes

AM/PM
Appt Location
Appt Doctor
Pet Owner Info
Pet Owner Name*
Pet Owner (prefix) Pet Owner (first) Pet Owner (last)
Pet Owner Phone*
Pet Owner Email*
Alt Owner Name
Alt Owner (prefix) Alt Owner (first) Alt Owner (last)
Alt Owner Phone
Alt Owner Email
Pet Owner Address *
Street Address City State / Province / Region ZIP / Postal Code Country
Preferred Clinic Location *
Willing to Consider Alternate Location(s)? *
- Yes
- No
Animal Patient Info
Pet Name*
Pet Species*
- Dog
- Cat
Pet Sex*
- Male
- Female
Neutered/Spayed*
- Yes
- No
Pet Breed*
Pet Date of Birth*
MM slash DD slash YYYY
Pet Age
Pet Color
Diagnosis*
Other Diagnosis*
I Have my Pet’s Recent Medical Records
- No
- Yes
To schedule the earliest possible Consultation and eliminate the delay and expense of duplicate testing, it is essential we review your pet’s recent medical records. Please attach any relevant medical records available.
If your primary and/or specialty/emergency vet(s) has additional relevant records, please contact them immediately and have the records emailed to us at records@animalcancercareclinic.com or submitted via our vet portal at CancerCareReferral.com. We will contact you within two business days to schedule your pet's consultation.
Drop files here or

Max. file size: 64 MB, Max. files: 100.
To schedule the earliest possible Consultation and eliminate the delay and expense of duplicate testing, it is essential we review your pet’s recent medical records.

Please immediately call your primary and/or specialty/emergency vet(s) to have relevant records emailed to us at records@animalcancercareclinic.com or submitted via our vet portal at CancerCareReferral.com.

We will contact you within two business days to schedule your pet's consultation.
I Have a Primary Veterinarian
- No
- Yes
Veterinarian Info
Primary Vet?
- Yes
Clinic Veterinarian
Clinic Vet (prefix) Clinic Vet (first) Clinic Vet (last)
Clinic Phone
Clinic Email
Clinic Name
Clinic Address
Clinic Street Clinic City Clinic State Clinic ZIP
Clinic Info
This field is hidden when viewing the form
Portal Clinic
Staff Member
Portal Clinic Vet
Phone
Email
This field is hidden when viewing the form
Medical Records
Please Attach any Relevant Medical Records Available
This field is hidden when viewing the form
Recent Bloodwork
(within past 3 months)
Drop files here or

Max. file size: 64 MB, Max. files: 100.
This field is hidden when viewing the form
Histopathology/Cytology Results
Drop files here or

Max. file size: 64 MB, Max. files: 100.
This field is hidden when viewing the form
Radiograph Reports or Images
Drop files here or

Max. file size: 64 MB, Max. files: 100.
This field is hidden when viewing the form
Ultrasound Report
(no images)
Drop files here or

Max. file size: 64 MB, Max. files: 100.
This field is hidden when viewing the form
Doctor’s Notes
Drop files here or

Max. file size: 64 MB, Max. files: 100.
This field is hidden when viewing the form
Additional Information
Additional Information
Briefly explain Pet’s condition, symptoms or any other information helpful for this referral.

In a hurry? Waiting for test results? Edits/Adds can always be made in MY REFERRALS after submission.

Call-In Referral

All Referrals

Pet Owner Info

Animal Patient Info

Veterinarian Info

Clinic Info

Medical Records

Additional Information