Consult Form

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Consult Form

Select a Consult *

Phone Consult
Email Consult
Recheck Consult

Name *

First

Last

Phone

Email *

Checkboxes *

By signing this Client Consent form, I affirm that I have read, understood, and agreed to acknowledge the inherent limitations of teleconsulting. I understand that the primary care DVM assumes liability for any recommendations or advice provided during the teleconsultation process.

PRIMARY CARE VETERINARIAN INFORMATION

Primary Care Veterinary Hospital *

Veterinarian Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

PATIENT INFORMATION

Pet’s Name *

Species *

Age *

Breed *

Sex *

Current or past medical conditions:

(autoimmune, endocrine, neoplasia, etc)

Current medications and dosages/frequencies:

Travel history:

Reason for consultation:

Any additional information that could be helpful:

Medical Records

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Signature *

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Date *

Name

Consult Form

Consult Form

PRIMARY CARE VETERINARIAN INFORMATION

PATIENT INFORMATION

Questions?

Contact Information