CortexVet Consultaiton

Patient Name

First NameLast Name

Your Hospital's Patient ID (Optional)

Patient Age (Years)

Breed

Patient Weight

Sex

History

Current Medications - DENOTE response or lack of thus far

Physical Exam Findings

Neurological Exam Findings

Any specific questions you are hoping to have answered?

Please upload PERTINENT medical documents (or email directly to admin@cortexvet.com)

Your Doctor's Name (The one requesting the consult)

First NameLast Name

Do you prefer A Text or Phone Call?

Phone number we should call/text to speak with Doctor

Please enter a valid phone number.Format: (000) 000-0000.

Email to Send Final Report

example@example.com

Billing Email (If different)

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 (Credit Card only needed if selecting "Pay Now")

Regular Consult - Report Returned in 24 hours

Medical Record review and phone consultation within 24 hours of requesting.

If your hospital prefers to be invoiced: Please "Invoice Hospital (Pay Later) to change the price to $0, and we will invoice the hospital at the email provided below.

$135.00 Payment Selection

ASAP Consultation

We call your doctor usually within 1 to 3 hours. Phone consultation with written report to follow in 24 hours.

If your hospital prefers to be invoiced: Please "Invoice Hospital (Pay Later) to change the price to $0, and we will invoice the hospital at the email provided below.

$190.00 Payment Selection

Video Exam Consultation - Scheduled

We evaluate the patient with the veterinarian live via Zoom or other video platform. This is a live virtual appointment with the doctor and neurologist; we will call the doctor above to schedule. It is up to your doctor if they do or do not want the client present. We are ONLY allowed to speak legally with veterinarians.

If your hospital prefers to be invoiced: Please "Invoice Hospital (Pay Later) to change the price to $0, and we will invoice the hospital at the email provided below.

$210.00 Payment Selection

Recheck

Recheck exam for any patient.

$95.00 Payment Selection

MRI Support, Report, or 2nd Opinion

MRI Acquisition Support ($250): We watch the MRI live with you (depending on your ability to share the images). No report (we are only helping you get the images and verbal comments).

MRI Acquisition with Report ($500): We watch the MRI live with you (depending on your ability to share the images). MRI report limited to neurological structures.

MRI Review: Second Opinion with report ($200): We will review the MRI, Medical Records, and provide a standard consultation report. This is NOT an MRI report.

If your hospital prefers to be invoiced: Please "Invoice Hospital (Pay Later) to change the price to $0, and we will invoice the hospital at the email provided below.

$250.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Direct Neurology Consultation Submission

Consultation Types (Credit Card only needed if selecting "Pay Now")*

Consultation Types (Credit Card only needed if selecting "Pay Now")