Professional Consultation Request Form
Welcome to our Professional Consultation Request Form. Before proceeding to make a request, please check the box below to signify your understanding and agreement. By checking this box, you acknowledge that you are requesting a professional consultation and report from one of our board-certified internists for an existing patient. Please be aware that your clinic will be invoiced for the consultation fee upon submission. The cost for this service is $80. Requests will be processed during normal business hours, Monday through Friday 8 am to 5 pm. The turnaround time ranges from 2-5 days based on the specialist schedule.
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Referring Information
Date
*
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Month
-
Day
Year
Date
Referring Doctor
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First Name
Last Name
Doctor
Please Select
Jennifer Harrison
Nicole Guma
Jean Ferreri
Hospital Name
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Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-Mail
*
Client & Patient Information
Client Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Name
*
Patient Date of Birth
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Month
-
Day
Year
Date
If you do not know exact birthday, please provide how many months or years your pet is.
Species
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Dog
Cat
Current Weight:
Current Medications:
Additional Information
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Please provide reason for submitting for review including status update
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Please list what you are submitting for review
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