(VC) Colleague Consult - Submission Form

Date of submission:

Month Day Year
We are looking forward to working with you!

If you are a veterinary professional already comfortable with locating and evaluating products in your area as well as creating dosing and monitoring plans....but just need a bit of extra guidance or support - this consult is for you. We can provide guidance on molecular profiles and assist in designing condition-specific monitoring plans. However, you should already be familiar with creating and maintaining a cannabis protocol to utilize this consult type.

This questionnaire will tell us more about your patient, the animal caregiver's goals for cannabis therapy, and your current treatment plan!
What type of Colleague Consult are you submitting? We will send you an invoice for $297 after receiving your submission. *

Behavior Case Consultation Oncology Case Consultation Neurology Case Consultation Pain/Internal Medicine Case Consultation
Where should we email the invoice?
We will send a Paypal invoice to this email.

Referral Information
How did you hear about us? *
Referral source: Other
Referral Source: Individual or Business Name

Submitting Practitioner Information
Name *

First Name Last Name
Credentials *
Business Name *
Email *
example@example.com
Phone
Please enter a valid phone number.

Client Information
Name *

First Name Last Name
Country of Residence *
State/Province *

Patient Information
Patient Name *
Species *
Other Species
Breed
Sex *
Weight *
Unit *

pounds(lbs) kilograms(kgs)
Estimated Date of Birth *

Month Day Year
Epoch Difference
Age (years)
Height (equine patients)

Medical History

Active problem list *

	Condition	Date of Diagnosis	Notes
1
2
3
4
5

Too many to type? Would you like to upload a file/document instead?

Yes
Active Problem List Upload

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Current prescription medications

	Medication	Date started	Dose	Notes
1
2
3
4
5
6
7
8
9
10

Too many to type? Would you like to upload a file/document instead?

Yes
Prescription Medication List Upload

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Current supplements & therapies

	Supplement/Therapy	Date started	Notes
1
2
3
4
5
6
7
8
9
10

Too many to type? Would you like to upload a file/document instead?

Yes
Supplements & Therapies List Upload

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Pertinent diagnostics

	Diagnostic test	Date performed	Interpretation
1
2
3
4
5
6

Medical records from the past year: *

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Bloodwork diagnostics from the past year: *

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INTERPRETATION of imaging diagnostics, if applicable:

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Does this patient have a history of heart disease? *
If yes, please describe the type and severity:
Physical Health Considerations
Emotional Health Considerations
Environmental Considerations
Current Diet, Dietary Restrictions and/or Allergies
Any additional notes on the patient's medical history?

Cannabis Considerations
Primary therapeutic goal(s) for cannabis use:
Ancillary therapeutic goal(s) for cannabis use:
Is this patient naive to cannabis? *
Describe the previous cannabis exposure/administration:
Describe the previous response to cannabis:
Does the animal caregiver already have a cannabis product they want to use? *
Please include a C.O.A (lab report) on the proposed product.

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Behavior Case Consultation Appropriate for any diagnosed non-oncological, non-neurological condition where the animal caregiver is interested in utilizing cannabis. Examples include decreased appetite due to stress, or a behavioral issue such as anxiety.
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Oncology Case Consultation Appropriate for any diagnosed neoplastic conditions where the animal caregiver is interested in utilizing cannabis for either definitive or palliative care.
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Neurology Case Consultation Appropriate for any diagnosed neurologic conditions where the animal caregiver is interested in utilizing cannabis.
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Pain/Internal Medicine Case Consultation Appropriate for any diagnosed pain or internal medicine condition where the animal caregiver is interested in utilizing cannabis. Examples include renal disease and gastrointestinal disease.
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