Chemotherapy Protocol Selection Form

Please Note: This form is to be used for patients who have already had a New Consultation from our specialists, and you have discussed recommendations with the client and are ready to start a NEW CHEMOTHERAPY PROTOCOL. Once a patient is on an established protocol, you will need to use those specific request forms to order additional chemotherapy (Chemo Recheck Forms)

**Must have CBC within 1 week in order to place the order for IV chemotherapy**

Each chemotherapy dose is shipped to your hospital in a closed delivery system and includes all required protective equipment that your team will need to administer chemotherapy safely in your practice.

Please visit www.veterinaryoncologypartners.com for more information.

Date

Today's Date

Client Name*

First NameLast Name

Patient Name*

CanineFelineOther

Weight (in pounds)*

Pounds, NOT Kg

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 number for texting payment link)*

Format: (000) 000-0000.

Veterinarian Fax Number*

Please enter a valid phone number. If you do not have Fax, then just enter 0s

Hospital / Practice Name*

Veterinary Hospital / Practice Address (Must be the practice address. We CANNOT ship chemotherapy directly to a pet owner)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Diagnosis*

You have selected "Other", please explain:*

***If you do not have a completed "New Consultation Report" for this patient, please CLICK HERE to submit this first. The case will be reviewed by one of our specialists, chemotherapy protocol recommendations will be made, and then you may submit this form to order the chemotherapy***

All chemotherapy will be shipped directly to your hospital (to the address above) from our partner FDA-certified fulfillment pharmacy. All injectable chemotherapy will be sent in a customized closed-delivery system to ensure USP/OSHA compliance. Your account will be billed immediately upon release of the consult and script request.

Shipping: Shipments will be sent via UPS 1 day overnight. You will receive an email with tracking information when the shipment is released from the pharmacy.

Personal Protective Equipment (PPE): Each shipment will come completely equipped with all personal protective equipment (gowns, gloves, etc) that your team needs to safely administer the medications. Injectable chemotherapy will arrive in a closed-delivery system, ready for administration.

**Additional chemotherapy doses will be slightly higher due to consultation fee. For this initial dose, you are not required to pay an additional fee as a consultant has already reviewed the case**

Authorizing Veterinarian Name*

By clicking the box below, I (listed above) authorize Veterinary Oncology Partners to script the first dose of chemotherapy to be sent to my hospital for the following chemotherapy protocol as previously recommended. All pricing includes shipping and handling. A payment link will be sent following submission: *

Please let us know if you have any specific concerns or questions!*