{"id":3760,"date":"2022-02-11T10:02:26","date_gmt":"2022-02-11T14:02:26","guid":{"rendered":"https:\/\/chuv.umontreal.ca\/english\/?page_id=3760"},"modified":"2024-03-06T10:27:46","modified_gmt":"2024-03-06T14:27:46","slug":"case-reference-at-dentistry-service","status":"publish","type":"page","link":"https:\/\/chuv.umontreal.ca\/english\/referring-a-case-to-the-chuv\/case-reference-at-dentistry-service\/","title":{"rendered":"Case reference at Dentistry Service"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column width=&#8221;1\/2&#8243;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text]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_column_text][\/vc_column][\/vc_row][vc_row][vc_column]<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume\" id=\"wpforms-4182\"><form id=\"wpforms-form-4182\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"4182\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/english\/wp-json\/wp\/v2\/pages\/3760\" data-token=\"b6d33db2d769263bbf4beecb3cc2f687\" data-token-time=\"1776461241\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-4182-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_38\">Reason for referral: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_38\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][38]\" required><\/div><div id=\"wpforms-4182-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_1\">Veterinarian: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" required><\/div><div id=\"wpforms-4182-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_2\">Referring clinic: <\/label><input type=\"text\" id=\"wpforms-4182-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/div><div id=\"wpforms-4182-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_3\">Clinic phone number: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-4182-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_4\">Other phone number: <\/label><input type=\"text\" id=\"wpforms-4182-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-4182-field_5-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_5\">Email: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-4182-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-4182-field_6-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"6\"><div id=\"wpforms-4182-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-4182-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_7\">First name and last name: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/div><div id=\"wpforms-4182-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_8\">Phone number #1: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-4182-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_9\">Phone number #2: (copy)<\/label><input type=\"text\" id=\"wpforms-4182-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-4182-field_10-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_10\">Email address of the client:<\/label><input type=\"email\" id=\"wpforms-4182-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" spellcheck=\"false\" ><\/div><div id=\"wpforms-4182-field_11-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"11\"><div id=\"wpforms-4182-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-4182-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_12\">Name of the animal: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-4182-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-4182-field_13\">Already a patient of the CHUV:<\/label><select id=\"wpforms-4182-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-4182-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_14\">Species: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/div><div id=\"wpforms-4182-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_15\">Breed (if known):<\/label><input type=\"text\" id=\"wpforms-4182-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-4182-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_16\">Age or date of birth: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" required><\/div><div id=\"wpforms-4182-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_17\">Weight: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4182-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required><\/div><div id=\"wpforms-4182-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-4182-field_18\">Sex: <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-4182-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-4182-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_19\">Anamnesis: <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-4182-field_19\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][19]\" required><\/textarea><\/div><div id=\"wpforms-4182-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_26\">Case history, active medical issues <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-4182-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" required><\/textarea><\/div><div id=\"wpforms-4182-field_27-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_27\">Treatments administered :<\/label><textarea id=\"wpforms-4182-field_27\" class=\"wpforms-field-large\" name=\"wpforms[fields][27]\" ><\/textarea><\/div><div id=\"wpforms-4182-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_28\">Current medication, doses, frequency of administration and length of administration:<\/label><textarea id=\"wpforms-4182-field_28\" class=\"wpforms-field-large\" name=\"wpforms[fields][28]\" ><\/textarea><\/div><div id=\"wpforms-4182-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-4182-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Hematology\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_29_1\">Hematology<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_29_2\" name=\"wpforms[fields][29][]\" value=\"Biochemistry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_29_2\">Biochemistry<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_29_3\" name=\"wpforms[fields][29][]\" value=\"Urology\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_29_3\">Urology<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_29_4\" name=\"wpforms[fields][29][]\" value=\"Bacterial culture\/sensitivity\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_29_4\">Bacterial culture\/sensitivity<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_29_6\" name=\"wpforms[fields][29][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_29_6\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-4182-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_30\">Other: please specify:<\/label><input type=\"text\" id=\"wpforms-4182-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-4182-field_31-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_31\">Summary:<\/label><textarea id=\"wpforms-4182-field_31\" class=\"wpforms-field-large\" name=\"wpforms[fields][31]\" ><\/textarea><\/div><div id=\"wpforms-4182-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-4182-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Radiographs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_32_1\">Radiographs<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_32_2\" name=\"wpforms[fields][32][]\" value=\"Ultrasound\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_32_2\">Ultrasound<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_32_3\" name=\"wpforms[fields][32][]\" value=\"Echocardiography\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_32_3\">Echocardiography<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_32_6\" name=\"wpforms[fields][32][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_32_6\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-4182-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_33\">Summary: <\/label><textarea id=\"wpforms-4182-field_33\" class=\"wpforms-field-large\" name=\"wpforms[fields][33]\" ><\/textarea><\/div><div id=\"wpforms-4182-field_34-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-4182-field_34\">Other relevant information :<\/label><textarea id=\"wpforms-4182-field_34\" class=\"wpforms-field-large\" name=\"wpforms[fields][34]\" ><\/textarea><\/div><div id=\"wpforms-4182-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-4182-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4182-field_35_1\" name=\"wpforms[fields][35][]\" value=\"I confirm\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4182-field_35_1\">I confirm<\/label><\/li><\/ul><\/div><div id=\"wpforms-4182-field_37-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"37\"><div id=\"wpforms-4182-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:admission-dentisterie@chuv.umontreal.ca\">admission-dentisterie@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=\"4182\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/chuv.umontreal.ca\/english\/wp-json\/wp\/v2\/pages\/3760\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-4182\" 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][\/vc_column_text][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_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text]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 referral to our specialist services, please contact your regular veterinarian. Thank you for your understanding.[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text][\/vc_column_text][vc_column_text]We will contact the owner to offer an appointment. However, you will&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-3760","page","type-page","status-publish","hentry","description-off"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Case reference at Dentistry Service - 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-dentistry-service\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Case reference at Dentistry Service - Internet English\" \/>\n<meta property=\"og:description\" content=\"[vc_row][vc_column width=&#8221;1\/2&#8243;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text]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 referral to our specialist services, please contact your regular veterinarian. Thank you for your understanding.[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text][\/vc_column_text][vc_column_text]We will contact the owner to offer an appointment. 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Referral requests completed directly by owners will not be processed. If your animal requires a referral to our specialist services, please contact your regular veterinarian. Thank you for your understanding.[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text][\/vc_column_text][vc_column_text]We will contact the owner to offer an appointment. 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