Consultation / Referral Form

I am submitting this form as a*

Pet Parent
Veterinary Practice

I am requesting a*

Quick Consultation
Patient Referral

Clinic Preference

Virginia Beach (520 Constitution Dr)
Chesapeake (228 Mt. Pleasant Rd)

My Email*

This address will receive a copy of this submitted form and follow-up replies (if applicable)

VETERINARIAN INFORMATION

Veterinarian Name*

Practice Name*

Practice Phone Number*

Practice Fax Number

Practice Email

CLIENT INFORMATION

Owner's Name*

First Last

Email*

Home Phone*

Cell Phone*

PATIENT INFORMATION

Pet's Name*

Date of Birth / Age*

Weight

Sex*

Intact Male
Neutered Male
Intact Female
Spayed Female

Breed*

Species*

Canine
Feline

QUESTIONNAIRE

Is patient newly diagnosed with one of the following corneal ulcers?*

Superficial, uncomplicated ulcer
Indolent ulcer
Mid-stromal ulcer
No

Animal Vision Center of Virginia is conducting a clinical trial to determine if the non-steroidal, anti-inflammatory medication Ketorolac influences the time for canine corneal ulcer healing. If your patient has been diagnosed with a superficial ulcer, indolent ulcer, or mid-stromal ulcer without malacia or significant infiltrates (deep stromal ulcers and descemetoceles are excluded), refer within 24 hours and we will offer reduced-cost visits and study medication for clinical trial participation. This includes 50% off initial visit and study medication, plus 30% off recheck visits and refills of study medication. We have allotted time in our schedule to accommodate same-day referrals.

For more information, you can visit our clinical trial webpage (opens in a separate window so that your form progress is not cancelled): animalvisioncenterva.com/nsaid-clinical-trial

To qualify for the clinical trial, it's important that the candidate has been diagnosed with a corneal ulcer and has just begun treatment with the following required therapy associated with their diagnosis (by the referring veterinarian or AVCVA):

Trial-qualifying therapy for SUPERFICIAL, UNCOMPLICATED ULCERS: Neomycin/Polymixin B Sulfates/Bacitracin Zinc ophthalmic ointment three times daily and gabapentin at 10mg/kg PO B-TID

Trial-qualifying therapy for INDOLENT ULCERS: Ofloxacin ophthalmic suspension 4 times daily and gabapentin at 10mg/kg PO B-TID *Diamond burr debridement and contact lens placement to be performed by Animal Vision Center of Virginia upon referral

Trial-qualifying therapy for STROMAL ULCERS: Ofloxacin ophthalmic suspension 4 times daily, Cefazolin 5% 4 times daily, and gabapentin at 10mg/kg PO B-TID

Duration of ocular symptoms?*

Duration of clinical signs?*

Ocular concern or tentative diagnosis:*

Additional ocular concern or tentative diagnosis (if applicable):

List any current medications taken by patient:

Any other problems or health concerns?*

If available/applicable, attach related photos (Maximum 5MB):

Drop files here or

Please send additional:
AVCVA Consultation/Referral Forms
AVCVA Business Cards
AVCVA Ocular Brochures

Date
Date Format: MM slash DD slash YYYY

Do you feel this is an ophthalmic emergency?*
Yes
No

Upon submitting this form, please call our office at 757-749-4838 if this is an urgent case.

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VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

QUESTIONNAIRE