Medical History
Full Name of Owner
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Agent Name or Alternate contact
First Name
Last Name
Alternate Contact Phone Number
-
Area Code
Phone Number
Relationship to Owner
Indicate if relative, agent, trainer, barn manager, or other
Animal Name/Identification
*
Name
Registered Name or "N/A"
Age (Years)
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Years
Sex
*
Please Select
Male - intact
Male - Castrated
Female
Other
Select Gender
Color/Markings
*
Coat colour
Breed
*
Type the breed
Animal Location
Barn Name
Street Address
City
State / Province
Postal / Zip Code
Appointment Date (If already scheduled)
.
Day
.
Month
Year
Date Picker Icon
What type of consultation are you seeking?
Please Select
General Telehealth
Specific Case Question
In-Person Consultation
Equine Dental Exam
Please select the type of consultation requested
Who would you like to work with?
Please Select
Dr. Carina Cooper
Dr. Jodie Santarossa
RVT Penny Radostits
Have you used CLASS services before?
*
No, first time
Yes, but for a different animal
Yes, for a different issue
Yes, this is a follow-up
Other
Regular Veterinarian
We only share records and plans with your vet if requested
Share records with veterinarian
*
Yes please!
No
Not sure yet
Other
Reason for Consultation
*
Include diagnosis, symptoms, or topic of choice
Duration of condition
*
Write "N/A" if not applicable. Write date of first symptom or approximate duration of clinical signs of concern
Brief History of concern or condition
*
Include timeline, progression, any treatments provided and result
Current medications
Include current medications only.
Diet/ Supplements
Provide details of diet
Vaccinations
Current vaccinations
Other history or information
Include any other details that may be helpful during the consultation
What goals do you hope to achieve during the consultation:
*
Diagnosis
Improved understanding
Second opinion
Alternative treatment options
Confidence in care
Therapy or Diagnostic plan
Support
Other
By submitting this form, I provide consent to treatment and services, have received an estimate for services to be provided, and acknowledge that payment is due at time of service
*
I agree
Submit
Clear Form
Should be Empty: