Tibial Plateau Leveling Osteotomy (TPLO) Referral Form

Patient's Name *

Species *

Breed *

Age / Date of Birth*

Sex *

Body weight (accepted surgical range: 12–44 kg) *

Body Condition Score *

Tentative Diagnosis *

Affected Limb *

Left pelvic limb
Right pelvic limb

Has Strathmore Veterinary Clinic previously evaluated this patient? *

Yes
No

Type of referral requested *

TPLO surgical consultation
TPLO surgery

Duration and progression of lameness *

Previous and current medications or treatments *

Previous orthopedic surgery or contralateral stifle disease *

Relevant medical history or comorbidities *

ORTHOPEDIC EXAMINATION FINDINGS

Cranial drawer / tibial thrust findings *

Joint effusion, pain, or instability *

Suspected meniscal injury *

Additional relevant orthopedic or neurologic findings

RADIOGRAPHIC INFORMATION

Radiographs performed *

Yes
No

Note: Sedated radiographs with calibration marker are strongly recommended for surgical planning. Repeat imaging may be required if quality is insufficient.

SCOPE CONFIRMATION (REQUIRED FOR TPLO REFERRAL)

Please confirm the following:

Primary, uncomplicated cranial cruciate ligament rupture suspected/confirmed *

Unilateral procedure requested (bilateral TPLO not performed at this time) *

Patient weight within accepted surgical range (12–44 kg) *

Owner aware that a pre-surgical consultation and planning radiographs are required prior to surgical booking *

Additional Comments / Referring Veterinarian Notes

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Tibial Plateau Leveling Osteotomy (TPLO) Referral Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

CLINICAL HISTORY

ORTHOPEDIC EXAMINATION FINDINGS

RADIOGRAPHIC INFORMATION

SCOPE CONFIRMATION (REQUIRED FOR TPLO REFERRAL)