Patient Consult Form

Save time and complete our patient consult form online, at your convenience. We look forward to seeing you soon!

Patient Consult Form

*For the most accurate and timely estimate and scheduling for surgical oncology cases, please include photos of the mass and any biopsy or cytology results

Referring Veterinarian Information

Referring Veterinarian's Name *

First

Last

Hospital Name *

Contact Email *

**Email address we'll use to communicate about the case, send our Surgery Day Email Confirmation and Surgery Paperwork + Invoice.

Hospital Phone

Client Information

Client Name *

First

Last

Patient Information

Patient Name *

Age *

Breed *

Sex *

Intact Male
Intact Female
Neutered Male
Spayed Female

Weight (in kilograms) *

If your practice records weight in pounds, please divide by 2.2 (1 kilogram = 2.2 pounds).

Chief Complaint & Relevant History

Summary of Physical Exam Findings *

Briefly describe the relevant exam findings that support your diagnosis.

Summary of Lab Results & Diagnostic Imaging *

Identify any notable information found on diagnostic testing. Please attach the lab results even if results are "Within Normal Limits".

Diagnosis *

Let's discuss if unsure. Please identify the affected side (right vs. left) when relevant.

Current Medications *

Please attach relevant radiographs & lab work results here

Drag & Drop Files, Choose Files to Upload You can upload up to 6 files.

Signature *

Clear Signature