Orthopedic Consultation / New Form

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Instructions

This service is for veterinarians only. If you are seeking medical advice for your own pet or animal, please contact your veterinarian. If this is an emergency, please call the main hospital at 217-333-5300.

Veterinarians, please answer the questions below to submit a consult request to the Orthopedic Service at the University of Illinois Veterinary Teaching Hospital. File upload is optional. Please note that this is only for consultation and not a referral request. Please make sure to include the reason or specific clinical questions for your consultation.

Referring Vet Contact Information

First Name*

Last Name*

Clinic Name*

Phone*

Email*

Preferred Method of Contact*

Phone

Fax number

Client Information

Name (First Last)*

Phone*

Patient Information

Name (First Last)*

Date of Birth (mm/dd/yyyy)*

Species/Breed*

Weight (lbs)*

Other Identifying Information

Patient History

Has the patient been seen by the University of Illinois VTH?*

Yes

Is this a recheck follow up?*

Yes

Reason for consultation (i.e. what is your clinical question?)*

Affected limb*

Front

Hind

Left

Right

Is the patient on medications?*

Yes

Maybe

What medications?

Did the lameness improve with medications?

Yes

Has the patient been restricted?

Yes

Did the lameness improve with restriction?

Yes

Does the patient have external coaptation on currently?*

Yes

Bloodwork*

Yes

Please upload bloodwork results

Systemic historical disease(s)

If there is any other pertinent information needed for consult, please include here. (ie. pain localization, wounds, etc.)

File upload #1 (optional)

Several images types supported (i.e. jpg, jpeg, gif, png, bmp). See farther down for video upload, not supported in regular "File Upload fields". Please include relevant historical radiographs.

File Upload #2

File Upload #3

File Upload #4

File Upload #5

File Upload #6

File Upload #7

File Upload #8

File Upload #9

File Upload #10

File Upload #11

File Upload #12

Video Upload - File Name

To send us a video, save your video with patient's name and clinic name, i.e. dog_clinic.mp4, and then email as an attachment to Upload Email. Enter the date sent in the box above to assist us in retrieving/matching your video to this consult request.

Submit

When ready to submit, check the box below and hit save. If urgent, please contact the orthopedic service at 217-265-5533 between 8a-4pm. After 4pm please call our emergency service at 217-333-5300.

Ready to submit*

Orthopedic Consultation