{"id":3742,"date":"2022-02-11T10:02:32","date_gmt":"2022-02-11T14:02:32","guid":{"rendered":"https:\/\/chuv.umontreal.ca\/english\/?page_id=3742"},"modified":"2024-03-06T10:25:43","modified_gmt":"2024-03-06T14:25:43","slug":"case-reference-at-interventionnal-medicine-service-ir","status":"publish","type":"page","link":"https:\/\/chuv.umontreal.ca\/english\/referring-a-case-to-the-chuv\/case-reference-at-interventionnal-medicine-service-ir\/","title":{"rendered":"Case reference at interventionnal medicine service (IR)"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column width=&#8221;1\/2&#8243;][vc_message]This form is used to<strong> determine the urgency of the consultation<\/strong>.<\/p>\n<p>The medical record will be consulted by the team only at the time of the consultation.<\/p>\n<p>This form is exclusively <strong>reserved for veterinarians and staff of veterinary clinics<\/strong>. Referral requests completed directly by owners <strong>will not be processed<\/strong>.<\/p>\n<p>If your animal requires a referral to our specialist services, please contact your regular veterinarian. Thank you for your understanding.[\/vc_message][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text][\/vc_column_text][vc_column_text]<a href=\"https:\/\/chuv.umontreal.ca\/english\/small-animal-hospital\/small-animal-hospital-services\/the-internal-medicine-and-cardiology-service\/\">Web page of Internal Medicine Service<\/a><br \/>\n<a href=\"https:\/\/chuv.umontreal.ca\/veterinaire\/accueil-veterinaires-referents\/hopitaux-services\/procedures-interventionnelles\/\">Web page of IR Service<\/a> (for veterinarians only)<\/p>\n<p><strong>Examples of interventional procedures:<\/strong><\/p>\n<ul>\n<li>Cystoscopy<\/li>\n<li>Removal of urinary stones by minimally invasive methods (lithotripsy and percutaneous cystolithotomy)<\/li>\n<li>Treatment of incontinence and difficulty in urinationLaser surgery (masses, strictures, ectopic ureter, etc.)<\/li>\n<li>Stent (trachea, urethra, ureter, blood vessels, etc.)<\/li>\n<\/ul>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column]<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume\" id=\"wpforms-4199\"><form id=\"wpforms-form-4199\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"4199\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/english\/wp-json\/wp\/v2\/pages\/3742\" data-token=\"2c320eb0ef506262350ae7bf14a0d121\" data-token-time=\"1779723191\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-4199-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_39\">Reason for referral: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_39\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][39]\" required><\/div><div id=\"wpforms-4199-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_1\">Veterinarian: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" required><\/div><div id=\"wpforms-4199-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_2\">Referring clinic: <\/label><input type=\"text\" id=\"wpforms-4199-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/div><div id=\"wpforms-4199-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_3\">Clinic phone number: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-4199-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_4\">Other phone number: <\/label><input type=\"text\" id=\"wpforms-4199-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-4199-field_5-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_5\">Email: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-4199-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-4199-field_6-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"6\"><div id=\"wpforms-4199-field_6\" class=\"wpforms-field-medium wpforms-field-row\"><h6>CLIENT INFORMATION<\/h6>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-4199-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_7\">First name and last name: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/div><div id=\"wpforms-4199-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_8\">Phone number #1: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-4199-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_9\">Phone number #2: (copy)<\/label><input type=\"text\" id=\"wpforms-4199-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-4199-field_10-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_10\">Email address of the client:<\/label><input type=\"email\" id=\"wpforms-4199-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" spellcheck=\"false\" ><\/div><div id=\"wpforms-4199-field_11-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"11\"><div id=\"wpforms-4199-field_11\" class=\"wpforms-field-medium wpforms-field-row\"><h6>PATIENT INFORMATION<\/h6>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-4199-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_12\">Name of the animal: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-4199-field_13-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_13\">Already a patient of the CHUV:<\/label><select id=\"wpforms-4199-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"I don&#039;t know\"  class=\"choice-3 depth-1\"  >I don't know<\/option><\/select><\/div><div id=\"wpforms-4199-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_14\">Species: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/div><div id=\"wpforms-4199-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_15\">Breed (if known):<\/label><input type=\"text\" id=\"wpforms-4199-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-4199-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_16\">Age or date of birth: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" required><\/div><div id=\"wpforms-4199-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_17\">Weight: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4199-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required><\/div><div id=\"wpforms-4199-field_18-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_18\">Sex: <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-4199-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required=\"required\"><option value=\"Unknown\"  class=\"choice-1 depth-1\"  >Unknown<\/option><option value=\"Male\"  class=\"choice-2 depth-1\"  >Male<\/option><option value=\"Sterilized male\"  class=\"choice-3 depth-1\"  >Sterilized male<\/option><option value=\"Female\"  class=\"choice-4 depth-1\"  >Female<\/option><option value=\"Sterilized female\"  class=\"choice-5 depth-1\"  >Sterilized female<\/option><\/select><\/div><div id=\"wpforms-4199-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_19\">Anamnesis: <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-4199-field_19\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][19]\" required><\/textarea><\/div><div id=\"wpforms-4199-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_26\">Case history, active medical issues <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-4199-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" required><\/textarea><\/div><div id=\"wpforms-4199-field_27-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_27\">Treatments administered :<\/label><textarea id=\"wpforms-4199-field_27\" class=\"wpforms-field-large\" name=\"wpforms[fields][27]\" ><\/textarea><\/div><div id=\"wpforms-4199-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_28\">Current medication, doses, frequency of administration and length of administration:<\/label><textarea id=\"wpforms-4199-field_28\" class=\"wpforms-field-large\" name=\"wpforms[fields][28]\" ><\/textarea><\/div><div id=\"wpforms-4199-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"29\"><label class=\"wpforms-field-label\">Laboratory tests performed (check please) Please send us all lab results as attached files, if available. : <\/label><ul id=\"wpforms-4199-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Hematology\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_29_1\">Hematology<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_29_2\" name=\"wpforms[fields][29][]\" value=\"Biochemistry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_29_2\">Biochemistry<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_29_3\" name=\"wpforms[fields][29][]\" value=\"Urology\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_29_3\">Urology<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_29_4\" name=\"wpforms[fields][29][]\" value=\"Bacterial culture\/sensitivity\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_29_4\">Bacterial culture\/sensitivity<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_29_5\" name=\"wpforms[fields][29][]\" value=\"Snaptest\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_29_5\">Snaptest<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_29_7\" name=\"wpforms[fields][29][]\" value=\"Pressure measuring\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_29_7\">Pressure measuring<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_29_6\" name=\"wpforms[fields][29][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_29_6\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-4199-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_30\">Other: please specify:<\/label><input type=\"text\" id=\"wpforms-4199-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-4199-field_31-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_31\">Summary:<\/label><textarea id=\"wpforms-4199-field_31\" class=\"wpforms-field-large\" name=\"wpforms[fields][31]\" ><\/textarea><\/div><div id=\"wpforms-4199-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"32\"><label class=\"wpforms-field-label\">Imaging tests performed (check please) Please send us all imaging reports and images, if available. :<\/label><ul id=\"wpforms-4199-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Radiographs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_32_1\">Radiographs<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_32_2\" name=\"wpforms[fields][32][]\" value=\"Ultrasound\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_32_2\">Ultrasound<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_32_3\" name=\"wpforms[fields][32][]\" value=\"Echocardiography\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_32_3\">Echocardiography<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_32_6\" name=\"wpforms[fields][32][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_32_6\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-4199-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_33\">Summary: <\/label><textarea id=\"wpforms-4199-field_33\" class=\"wpforms-field-large\" name=\"wpforms[fields][33]\" ><\/textarea><\/div><div id=\"wpforms-4199-field_38-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"38\"><label class=\"wpforms-field-label\">Concerning the specialised follow-up visits, I would like them to be carried out by: <\/label><ul id=\"wpforms-4199-field_38\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_38_1\" name=\"wpforms[fields][38][]\" value=\"My care\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_38_1\">My care<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_38_2\" name=\"wpforms[fields][38][]\" value=\"The CHUV\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_38_2\">The CHUV<\/label><\/li><\/ul><\/div><div id=\"wpforms-4199-field_34-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-4199-field_34\">Other relevant information :<\/label><textarea id=\"wpforms-4199-field_34\" class=\"wpforms-field-large\" name=\"wpforms[fields][34]\" ><\/textarea><\/div><div id=\"wpforms-4199-field_35-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"35\"><label class=\"wpforms-field-label\">I confirm that I have obtained prior permission from the animal&#039;s owner to communicate this information <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-4199-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4199-field_35_1\" name=\"wpforms[fields][35][]\" value=\"I confirm\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4199-field_35_1\">I confirm<\/label><\/li><\/ul><\/div><div id=\"wpforms-4199-field_37-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"37\"><div id=\"wpforms-4199-field_37\" class=\"wpforms-field-medium wpforms-field-row\"><p>Please send a copy of the medical file including imaging and laboratory tests (.pdf, .jpg, .doc, .docx, .xls, .xlsx,) at <a href=\"mailto:medecine-interventionnelle@chuv.umontreal.ca\">medecine-interventionnelle@chuv.umontreal.ca<\/a> with the name of the patient and the department to which they are referred in the subject line<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"4199\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/chuv.umontreal.ca\/english\/wp-json\/wp\/v2\/pages\/3742\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-4199\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/chuv.umontreal.ca\/english\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->[vc_column_text]We will contact the owner to offer an appointment. However, you will be notified if we are unable to see the animal within a reasonable time frame based on its condition.[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column width=&#8221;1\/2&#8243;][vc_message]This form is used to determine the urgency of the consultation. The medical record will be consulted by the team only at the time of the consultation. This form is exclusively reserved for veterinarians and staff of veterinary clinics. Referral requests completed directly by owners will not be processed. If your animal requires a&hellip;<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":3679,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-3742","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>Case reference at interventionnal medicine service (IR) - 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\/referring-a-case-to-the-chuv\/case-reference-at-interventionnal-medicine-service-ir\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Case reference at interventionnal medicine service (IR) - Internet English\" \/>\n<meta property=\"og:description\" content=\"[vc_row][vc_column width=&#8221;1\/2&#8243;][vc_message]This form is used to determine the urgency of the consultation. The medical record will be consulted by the team only at the time of the consultation. This form is exclusively reserved for veterinarians and staff of veterinary clinics. Referral requests completed directly by owners will not be processed. 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