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)
Sex
Species
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
Has this patient been definitively diagnosed with cancer based on histology or cytology?
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:
General Assessment
Please choose all that apply. You can give additional details as indicated if you select the "Other option:

Other
Recent labwork (within the last month)?
Date of most recent lab work

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

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Has this patient had any imaging (radiographs, ultrasound, CT)?
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)
Has this patient received ANY steroids within the last month?
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

Tax

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

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New Patient Consultation

My Products*

My Products