CortexVet Consultaiton

Patient Name*

First NameLast Name

Your Hospital's Patient ID (Optional)

Patient Age (Years)*

Breed*

Patient Weight*

kgslbs

Sex*

Female - SpayedFemale IntactMale - CastratedMale Intact

General Topic

	Choose One
Seizures
Down/Paralyzed Animal
Other

History*

Current Medications

Physical Exam Findings*

Neurological Exam Findings *

Any specific questions you are hoping to have answered?

Please upload medical documents (front desk can also email thebraindogtor@gmail.com)

Requesting Doctor Name*

First NameLast Name

Your Hospital Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Doctor Phone Number for Phone/Text Communication*

Please enter a valid phone number.

Email Where to Send Report*

example@example.com

I understand that the VCPR (veterianry-client-patient-relationship) and primary responsibility for care is retained by the veterinarian/hospital requesting the consultation. I understand this consultation serves only to assist me in providing care for my patient, as a VCPR cannot be created via telecommunications in most states. I recognize that the virtual environment has its limitations and that all recommendations are based on information available at the time of the consultation; shared between veterinarians and the medical records. I will use consult recommendations as I feel are in the best interest of my patient and any changing status. *

Consultation Types*

Asynchronous - Report Returned in 24 hours

$135.00

ASAP Consultation

$190.00

Invoice Hospital - 24 hours - $135Hospital will be invoiced the cost of the consultation at $135

$ Free

Invoice Hospital - ASAP - $190Hospital will be invoiced the cost of the consultation at $190

$ Free

Credit Card Details - (not needed for invoice options)
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Direct Neurology Consultation Submission