(VC) Colleague Consult - Submission Form

Date of submission:

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

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? *

Standard Case Consultation ($115.00) Integrative Oncology Consultation ($247.00) Integrative Neurology Consultation ($247.00)
Where should we email the invoice? *
We will send a Paypal invoice to this email.

Active problem list *

Condition

Date of Diagnosis

Notes

Current prescription medication

Medication

Date started

Dose

Notes

Current supplements & therapies

Supplement/Therapy

Date started

Notes

Pertinent diagnostics

Diagnostic test

Date performed

Interpretation

Please include a copy of the patient’s most recent bloodwork and any diagnostics performed within the last 2 months.

Cancel of
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?

We are looking forward to working with you!