Vet Specialist Consultants - Consultation Form

PDF Form
Download the pdf version of our consultation form to print and fill out by hand.

consultation_form.pdf

(22kb, requires Adobe reader)

Please fill out all appllicable fields and click submit this your form data to Dr. Boria. Pertinent test results and reports can be faxed to 855-662-6838, or emailed to info@vetspecialistconsultants.com.

Dr. Boria will report back to you by the end of the next consulting day (Monday through Friday 8am- 6 pm EST, by your preferred method (phone, fax, or email).

Requesting Clinician Name

E-mail

Phone

Fax

Preferred Contact Method:

Address

City, State, Zip

, ,

Patient Information

Name

Species

Canine

Feline

Breed

Sex

Age

Weight

First Consult or Follow-up?

First Consult
Follow-up consultations for ongoing case management

Priority

Routine

Emergency

Medical Information

Pertinent Medical or Cancer History:

Past Medical History:

Laboratory/Pathology:

CBC
Serum Chem
U/A
Biopsy
Cytology

Regional Lymph Node Evaluation:

Yes (Biopsy)
Yes (Aspirate)
No

Current Drug Therapy and/or response to previous medications:

Diagnostic Imaging:

CT/ MRI
US

Radiographs:

Thoracic
Abdominal
Other:

Summary of Imaging Findings:

Diagnosis:

Pertinent test results and reports can be faxed to 855-662-6838,
or emailed to info@vetspecialistconsultants.com