Online Consult History

BEHAVIORAL MEDICINE NEW PATIENT CONSULTATION
READ THIS FIRST!

Living with a pet with a behavior problem can be stressful. Luckily, you are at the right place to get help.
1. If your pet has not seen Dr. Radosta or any of the doctors in her practice you must complete this form first before you book a Zoom appointment.
2. You do not have to speak with Dr. Radosta to receive a complete treatment plan. This form, the videos and your pet's medical record will provide plenty of information for her to help your pet.
3. If you would like to speak with her after you submit this form, videos, and medical records, you can book a 30-minute appointment at this link: Book a 30 minute Zoom appointment with Dr. Radosta
4. State and Federal laws are clear regarding veterinary-client-patient relationships. To stay in compliance with current laws
  1. Dr. Radosta cannot recommend treatment including medications directly to you.
  2. Dr. Radosta cannot prescribe directly for your pet.
5. Because of those pesky state and federal laws, the treatment plan will be sent to your veterinarian. Your veterinarian will then send it to you and prescribe medications for your pet.
Submitting a consult.
1. Fill out the consult history form, you are in the right place to complete this step!
2. Drop 2-4 videos (total of no more than 4 minutes of video) into the link at the bottom of this form. See below for more information on how to video your pet.
3. You can just drop your pet's medical record in the consult form. Please feel free to save the form and work on it later if you need to do so.
4. If you don't have your pet's medical records, call your veterinarian and ask them to send them to vetbehavior911@gmail.com.
5. Pay for your pet's consultation within the history form (you are here!).
When we receive all documents above and payment, Dr. Radosta will create a custom treatment plan for your pet and email your veterinarian within 2 business days as long as the consult is submitted during the consult processing dates below.

If you have questions, contact us at: vetbehavior911@gmail.com

***Consults are processed Monday-Thursday.***
Hospital and Veterinarian
Hospital*
Referring Doctor*
Best email for Doctor/Hospital*
Best Phone Number for Doctor/Hospital*

Area CodePhone Number
Pet Parent
Your Name*

First NameLast Name
Your Email
example@example.com
Your Pet
Your pet's name*
Species*

CanineFelineAvian
Weight in pounds*
Breed*
Age in years
Gender Status*

Male intactMale neuteredFemale intactFemale spayed

Presenting Compliants

	Age of onset	Frequency
Aggression
Anxiety
Fear
Fly Snapping
Elimination in the house
Leash Reactivity
Litterbox issues
Noise phobia
Separation anxiety
Storm/Noise phobia
Tail chasing
Run in circles

Clinical Signs
List the two most important problems to be addressed. This way, I can make sure to address those completely.
Aggression

If your pet exhibits aggression please fill out this section. If not, go to the next section.
How old was your pet when you first noticed the aggression?

Before 1 year1-3 years3-7 years8+ years
Situations in which aggression is exhibited. Check all that apply.

BathedBrushedSees bikesCollar taken off/put onCorrectedEatingEyes wipedExamined by veterinarianGroomed (professional groomer)Has a boneHas foodHuggedIn carIn his bedIn your bedIn the houseItem is droppedOn walksIn the yardLeash put on/taken offLiftedLooked atNails trimmedPlayingPushed/pulledReached forSpoken toTouchedSees kidsSees/hears motorcycleSleepingWhen startledToweledOther
If Patient has bitten, number of bites

1-23-5>5
Targets of aggression. Check all that apply.

Familiar adultsUnfamiliar adultsVeterinarianFamiliar dogsUnfamiliar dogsFamiliar childrenUnfamiliar childrenGroomerFamily catWild animals outside of the homeCats outside of the homeOther
Aggression clinical signs. Check all that apply.

Bare teethBarkBite (mouth contacts victim, no broken skin)Bite (mouth contacts victim, skin broken)ClawDilated pupilsEars backGlassy eyedGrowlHead downHair up on back (piloerect)HissLick lipsLower bodyLungePantRear up on hind legsScratchSnapping-Opening and closing of mouth, no contact to victimStiff bodySwatTense musclesTail over backTuck tailTurn head awayTry to get awayWag tailYawnZones outPatient doesn't exhibit any of these clinical signsOther
Storms/Sounds

If your pet exhibits fear or anxiety during storms or loud noises please fill out this section. If not, go to the next section.
How old was your pet when you first noticed the fear of sounds?

Before 1 year1-3 years3-7 years8+ years
Triggers

Electronic beepingConstructionThunderLarge truck soundsFood sizzling in a panText alert soundOther
Clinical Signs

PantsPacesHyper salivates (drools)Acts aggressively if you try to move himTremblesHowlsBarksComes to find youDestructiveOther
Recovery

Immediately10 minutes10-20 minutes20-30 minutes30-40 minutes40-50 minutes50-60 minutes1-3 hours3-6 hours6-12 hours12-24 hoursGreater than one dayOther
Separation Behaviors

If your pet exhibits anxiety or distress when left alone please fill out this section. If not, go to the next section.
How old was your pet when you first noticed that your pet was stressed when alone?

Before 1 year1-3 years3-7 years8+ years
Separation related behaviors

Attempts to HideAttempts to find personBarksCan't be crated/confinedClimbing on top of furnitureDefecationDepressionDestructionHowlsHypersalivationPacingPantingReluctance to eatTremblingUrinatingVomitingWhiningOther
Does the patient exhibit the behavior every time that the pet parent departs?

YesNo
Does the patient exhibit the behavior only when alone?

YesNo
Displacement/Compulsive behaviors

If your pet exhibits any of the behaviors below, please fill out this section. If not, go to the next section.
How old was your pet when you first noticed the behavior?

Before 1 year1-3 years3-7 years8+ years
Displacement/compulsive

Fly snappingLight chasingPicaShadow chasingOther
Urination/Defecation in the house (Dogs)

If your pet exhibits any of the behaviors below, please fill out this section. If not, go to the next section.
Urination/Defecation in the house

My dog was at one time housetrained (didn't urinate or defecate in the house unless ill)My dog is trained to urinate/defecate on pee pads and doesn't go outside to urinate/defecate.My dog has accidents when in the crate.My dog is trained to urinate/defecate on pee pads and outside.My dog has accidents when I am home and when he is alone.My dog is trying to urinate/defecate on pee pads, outside, and also in other places (pet potty).My dog only has accidents during storms or when he is scared.My dog has urine accidents in the house..My dog has defecation accidents in the houseMy dog only has accidents when he is completley alone.Other
For cats only

For behavioral periuria consultations pictures or videos of the litterboxes and their locations must be submitted.
Elimination behavior (check all that apply)

Urination outside of the litterboxLarge amountsVertical surfacesSmall amountsHorizontal surfacesStanding to urinate with tail twitchingCurved body postureMeows when leaves boxTries to cover in boxTries to cover outside of boxLarge amounts of feces outside of the boxSmall amounts of feces outside of the boxPatient doesn't exhibit any of the above clinical signsUnknownOther
Situations (check all that apply)

Owner is homeOwner is not homeSoft surfacesHard surfacesHigh surfacesLow surfacesOther
Number of cats in household
Number of litterboxes in household
Type of litter
List any additional problems that you would like addressed.
Other body systems

Changes in overall health have a major impact on behavioral clinical signs. Make sure to check all that apply and use the "other" field if necessary.
Other body systems

Changes in appetiteWeight lossWeight gainMuscle wastingOrthopedic painChronic otitis externaChronic pyodermaPruritusNeurologic painChanges in defecation (diarrhea, constipation)Recurrent urinary tract infectionsChanges in urination (frequency, location, pain)The patient has none of the changes listed aboveEndocrine (diabetes, Cushing's, Addisons, hypothyroidismOther
Medical treatments

Your patient's medical records including images will be reviewed. If your patient has been on a medication or supplement which is not listed in the medical record, please add it below.
Current Medications (list all) *
Medical history (Master diagnosis list) Please list current and past diagnoses. *
Additional history
***PLEASE DON'T SKIP THIS STEP***

The videos allow Dr. Radosta to see your pet in their home environment. This is extremely important as a diagnosis and treatment plan should not be made on the history alone, but also on observation.

Upload 2-4 videos (total of no more than 4 minutes of video) and medical record below.

Do not endanger your pet or yourself making videos! Do not provoke the behavior.

Helpful videos can include:

1. The environment (home, yard, car)

2. Your pet interacting with you or others.

3. Your pet during a stressful situation as long as it is safe (storms, when you are gone, in the car, when visitors come over).

If you would like a separate link for the videos you can submit them directly instead of dropping them into this form at this link:

https://www.dropbox.com/request/pI2w3pXbf6Bq1uDjR9Uq
Dr. Radosta often teaches veterinarians healthcare team members, pet parents and dog trainers on the behavior of animals. We would like permission to use those videos for any lawful purpose, including, but not limited to, website, social media accounts, and promotional materials, either digital or in print, in perpetuity. By selecting yes, below, I authorize Dr. Radosta to edit, alter, share, remix, tweak, build upon or in any way alter the photographs or videos mentioned above. I also waive any rights of privacy or compensation associated with the use of my or my pet’s image(s) and name(s) for the personal or commercial purposes outlined above.*

Yes, I consentNo
SUBMIT MEDICAL RECORDS AND VIDEOS HERE*

Browse Files

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Pay for your consult here.

Full Veterinarian to Veterinarian Telehealth Consultation $300.00

What you get: A 2-4 page report with an assessment of your patient's behavior; differential diagnosis list; initial medication, management and safety and behavior modification plan. Follow up questions regarding the initial consultation via email (vetbehavior911@gmail.com) for up to 14 days after the consult is returned to you at no additional cost.

Total $0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I acknowledge that my primary care veterinarian, whom I have listed above, is my treating veterinarian. This diagnostic intake doesn't establish a veterinarian-client-patient relationship as mandated by federal or state law. As such, Dr. Radosta cannot recommend a medication for my pet directly to me in writing or in any other way. Instead all treatment instructions will be sent to my veterinarian who will then send them to me and will prescribe all medications.

I am the owner(s) of the animal(s) seeking behavioral medicine treatment through an online consult with Dr. Radosta. Behavioral treatment, training and advice when properly maintained after completion can be very helpful in resolving problem behaviors in animals. Because each pet is an individual, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior including aggression is unpredictable and will remain unpredictable after its treatment. Dr. Radosta cannot promise that the animal's treatment, training or advice will eliminate the animal's potential danger to persons or completely control the animal's aggressiveness. Animals should be closely supervised particularly around children and infants and should be controlled at all times including conformance with local ordinances and "leash laws."

I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.
I have read the above statement, acknowledge it and agree to what is written there. Signature (Use your track pad and sign with your finger or use your mouse)*

Clear
e-Signature*

First NameLast Name
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BEHAVIORAL MEDICINE NEW PATIENT CONSULTATION

Hospital and Veterinarian

Pet Parent

Your Pet

Clinical Signs

For cats only

Other body systems

Medical treatments