(VC) Colleague Consult - Submission Form

Date of submission:

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

If you are a veterinarian or other veterinary professional already comfortable with locating and evaluating products in your area and creating dosing and monitoring plans....but just need a bit of extra guidance or support - this consult is for you.

(If you are a animal caregiver seeking guidance for your own animal, please sign up for one of our Cannabis Guidance Programs!)

We can provide provide guidance on molecular profiles and assist in designing appropriate monitoring plans. However, you should already be familiar with creating and maintaining a cannabis protocol to utilize this consult.

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.

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

Cancel of

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

Cancel of

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

Cancel of

Pertinent diagnostics

	Diagnostic test	Date performed	Interpretation
1
2
3
4
5
6

Medical records from the past year: *

Cancel of
Bloodwork diagnostics from the past year: *

Cancel of
INTERPRETATION of imaging diagnostics, if applicable:

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?

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.

Cancel of
Additional notes/questions on proposed product:
Is there anything else we should know about this patient or their caregiver?

Payment
Make a Selection: *
prev next ( X )
Standard Case Consultation Appropriate for any diagnosed condition that is not an oncology or neurology case. Examples of cases include: behavioral disorders, GI conditions, any pain/inflammation conditions.
$ 197.00

Integrative Oncology Consultation Appropriate for any diagnosed neoplastic conditions where the animal caregivers are interested in utilizing cannabis for either definitive or palliative care.
$ 297.00

Integrative Neurology Consultation Appropriate for any diagnosed neurologic condition. Examples of cases include: seizure disorders, anxiety disorders, unresponsive neurologic pain conditions.
$ 297.00

Total

$ 0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty: