New Patient Consultation

New Patient Consultation
Please fill out the following fields and upload all relevant documents. A specialist will review the case history, imaging, reports, and make recommendations as indicated. You will receive a consultation report sent to the email provided within 24hrs (1 business day). Your report may suggest additional diagnostics for staging purposes; it will also provide treatment options, expectations and prognosis based on current data.
Date

MonthDayYear
Today's Date
Client Name*

First NameLast Name
Client's Phone Number*
Format: (000) 000-0000.
Client's Email*
We will be emailing each client a link to complete a medical record release for each patient.
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Name*
Age (Years)*
(For example: 1.5 yrs)
Male NeuteredMaleFemale SpayedFemale
CanineFeline
Breed of Dog*
Breed of Cat*
Breed
Weight (in pounds)*
Veterinarian Name*

First NameLast Name
Veterinarian Email (The final report will be sent here. We CANNOT send directly to the pet owner)*
example@example.com
Veterinarian Phone Number (cell phone or office number)*
Format: (000) 000-0000.
Hospital / Practice Name*
Veterinary Hospital / Practice Address (This address is where chemotherapy will be sent. We CANNOT send chemotherapy directly to the Pet Owner)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Yes - interested in disease information, prognosis, and/or treatment planNo - seeking input for additional work-upOther
Diagnosis*
Date of Diagnosis*

MonthDayYear
Date of original cancer diagnosis or start of related clinical signs
Please upload any Cytology / Histology reports here.

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You have selected "Other", please explain below:
GOOD - Quality of life appears good despite recent cancer diagnosis.OK - Pet not feeling great, new diagnosis is likely the cause.CONCERNED - Pet feeling poorly and significant changes noted on PE, bloodwork or owner history.POOR - Pet having significant health problems from recent diagnosis and/or other concurrent illnesses.
VomitingDiarrheaAnorexiaDecreased appetiteSevere weight lossSevere LethargyLamenessAbdominal painIncreased thirst / drinkingIncreased urinationIncreased ALT / hepatopathyNeutropenia (less than 1,500 total neutrophils)Thrombocytopenia (less than 100,000)AnemiaOther
YesNo
Date of most recent lab work*

MonthDayYear
Date
Please upload most recent labwork (CBC, Chemistry).

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YesNo
Please attach all radiographs, ultrasound images, and all reports for imaging below (JPEG/JPG/PNG/GIF images accepted):

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Please attach all the medical notes / SOAPs below:

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Doctor Case Summary / History of recent events
ALL Current Medications (including dose and frequency)*
(Ex: Carprofen 50mg PO q 24h)
YesNo
Please list the steroid given and dosage, including tapering schedule if indicated.
(Ex: Prednisone 10mg PO q 12h)
What was the Date that Steroids were last given?

MonthDayYear
**Choose Today's date if patient still on steroids**
Concurrent and/or Previous Diagnoses*
Write "None" if nothing to add.
Please let us know if you have any specific concerns or questions!
Authorizing Veterinarian Name*

My Products*

Initial Consultation

$199.00

Optional Onboarding Chemotherapy Training Kit (Currently available in the following states: KY, IN, IL, FL, CO, NJ)

This kit contains a training binder, access to video tutorials, a chemotherapy spill kit, closed-delivery system demonstration supplies, and online personal training modules delivered via Zoom. Only need to purchase ONCE for your practice (NOT PER PATIENT).

$125.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card Details
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