This form is to request case consultation regarding planned re-staging or follow-up on a patient whom VOP has consulted on in the past. This is also an appropriate form to use if your patient has completed a chemotherapy protocol through VOP and is now out of remission.
VOP requires all supporting documentation to be submitted in an electronic format. This online form allows you to upload electronic copies of all labwork in a drag-and-drop format. VOP does not allow Email or Fax submissions at this time.
VOP requires all supporting documentation to be submitted in an electronic format. This online form allows you to upload electronic copies of all labwork in a drag-and-drop format. VOP does not allow Email or Fax submissions at this time.
Information required to complete this form:
- Client and Patient Information (including patient weight)
- Your hospital information (including phone, address, and email for reporting)
- Updated History / Clinical Signs
- Recent labwork (CBC required)
- Diagnosis
- Current Medication
- Protocol choice, options include the following:
- CHOP
- Vinblastine
- CCNU (Lomustine)
- Adriamycin
- Carboplatin
- Leukeran
- Vinorelbine
- Mitoxantrone
- Palladia
- Piroxicam and/or Chlorambucil