{"id":2187,"date":"2017-12-06T13:30:38","date_gmt":"2017-12-06T13:30:38","guid":{"rendered":"http:\/\/chuv.umontreal.ca\/english\/?page_id=2187"},"modified":"2017-12-06T13:30:38","modified_gmt":"2017-12-06T13:30:38","slug":"online-case-reference-system-small-animal-hospital","status":"publish","type":"page","link":"https:\/\/chuv.umontreal.ca\/english\/contact\/online-case-reference-system-small-animal-hospital\/","title":{"rendered":"Online Case Reference System (Small Animal Hospital &#8211; interventional medicine)"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][vc_column_text]<\/p>\n<h1><strong>Online Case Reference System<br \/>\n(Interventional Medicine Service &#8211; Small Animal Hospital)<\/strong><\/h1>\n<p>Please note that this form is for the exclusive use of veterinarians.<\/p>\n<p><span style=\"color: #ff0000\"><strong>Under construction. Please do not use this form.<\/strong><\/span><\/p>\n<p><a href=\"http:\/\/chuv.umontreal.ca\/english\/wp-content\/uploads\/sites\/2\/2017\/12\/formulaire-de-r\u00e9f\u00e9rence-hac-anglais.pdf\">.pdf reference form for printing and sending by email<\/a>[\/vc_column_text][vc_empty_space]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2190-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"2190\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/english\/wp-json\/wp\/v2\/pages\/2187#wpcf7-f2190-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"2190\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2190-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><label> Type of visit<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Typeofvisit\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"Typeofvisit[]\" value=\"Urgent\" \/><span class=\"wpcf7-list-item-label\">Urgent<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"Typeofvisit[]\" value=\"Next available appointment\" \/><span class=\"wpcf7-list-item-label\">Next available appointment<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Reference reason<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Referencereason\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Referencereason\" \/><\/span> <\/label>\n<\/p>\n<p><label> If your client has already made an appointment, please indicate the pre-submission number sent to you by email : <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"preadmission\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"preadmission\" \/><\/span>\n<\/p>\n<p>Informations about the referral veterinarian\n<\/p>\n<p><label> Referring clinic<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Referringclinic\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Referringclinic\" \/><\/span> <\/label>\n<\/p>\n<p><label> Veterinarian<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Veterinarian\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Veterinarian\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PrincipalPhonenumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"PrincipalPhonenumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Second phone number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Secondphonenumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Secondphonenumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Vetemail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"Vetemail\" \/><\/span> <\/label>\n<\/p>\n<p>Informations about the client\n<\/p>\n<p><label> First name and last name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Clientname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Clientname\" \/><\/span> <\/label>\n<\/p>\n<p><label> Phone number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Clientphonenumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Clientphonenumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Second phone number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Clientsecondphonenumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Clientsecondphonenumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Clientemail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"Clientemail\" \/><\/span> <\/label>\n<\/p>\n<p>Informations about the patient (If the medical file is sent by email at reference@chuv.umontreal.ca or join to this form, you can skip this section.)\n<\/p>\n<p><label> Medical file (Max 2 MB) <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Medicalfile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"Medicalfile\" \/><\/span>\n<\/p>\n<p><label> Name of the animal<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Animalname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Animalname\" \/><\/span> <\/label>\n<\/p>\n<p><label> Second phone number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Clientsecondphonenumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Clientsecondphonenumber\" \/><\/span> <\/label>\n<\/p>\n<p><label> Check if already referred in the past :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alreadyreferredinthepast\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"alreadyreferredinthepast[]\" value=\"already referred in the past\" \/><span class=\"wpcf7-list-item-label\">already referred in the past<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> Species<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Species\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Species\" \/><\/span> <\/label>\n<\/p>\n<p><label> Breed (if known)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Breed\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Breed\" \/><\/span> <\/label>\n<\/p>\n<p><label> Age or date of birth<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Ageordateofbirth\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Ageordateofbirth\" \/><\/span> <\/label>\n<\/p>\n<p><label> Weight<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Weight\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Weight\" \/><\/span> <\/label>\n<\/p>\n<p><label> Sex<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Sex\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Sex\"><option value=\"Male\">Male<\/option><option value=\"Sterilized male\">Sterilized male<\/option><option value=\"Female\">Female<\/option><option value=\"Sterilized female\">Sterilized female<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span>\n<\/p>\n<p><label> Anamnesis<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Anamnesis\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Anamnesis\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> Diagnostic<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Diagnostic\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Diagnostic\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> Summary of laboratory results<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Summaryoflaboratoryresults\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Summaryoflaboratoryresults\"><\/textarea><\/span> <\/label>\n<\/p>\n<p>Max 2 MB per document<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Laboresults\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"Laboresults\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"Laboresults2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"Laboresults2\" \/><\/span>\n<\/p>\n<p><label> X-rays<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"x-rays\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"x-rays\"><\/textarea><\/span> <\/label>\n<\/p>\n<p>Max 2 MB per document<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"xrays1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"xrays1\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"xrays2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"xrays2\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"xrays3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"xrays3\" \/><\/span>\n<\/p>\n<p><label> Treatments and treatments responses<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"treatments\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"treatments\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> Other relevant informations<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Otherinfos\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Otherinfos\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> Comments about the online case reference system<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Comments\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Comments\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]You can also send us your documents (medical file, laboratories, x-rays, etc.) to <a href=\"mailto:reference@chuv.umontreal.ca\">reference@chuv.umontreal.ca<\/a>. The total limit per shipment is 20 MB. Please note that you can send us more than one email if necessary, being careful to indicate the patient&#8217;s name in the title of the email.[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][vc_column_text] Online Case Reference System (Interventional Medicine Service &#8211; Small Animal Hospital) Please note that this form is for the exclusive use of veterinarians. Under construction. Please do not use this form. .pdf reference form for printing and sending by email[\/vc_column_text][vc_empty_space][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]You can also send us your documents (medical file, laboratories, x-rays, etc.) to reference@chuv.umontreal.ca. The&hellip;<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":32,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2187","page","type-page","status-publish","hentry","description-off"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Online Case Reference System (Small Animal Hospital - interventional medicine) - Internet English<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/chuv.umontreal.ca\/english\/contact\/online-case-reference-system-small-animal-hospital\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Online Case Reference System (Small Animal Hospital - interventional medicine) - Internet English\" \/>\n<meta property=\"og:description\" content=\"[vc_row][vc_column][vc_column_text] Online Case Reference System (Interventional Medicine Service &#8211; Small Animal Hospital) Please note that this form is for the exclusive use of veterinarians. 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