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

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?*

Text MessagingPhone Call

Your Hospital Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone number we should call/text to speak with Doctor*

Please enter a valid phone number.

Email to Send Final 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 Medical Record review and phone consultation within 24 hours of requesting.

$135.00

ASAP Consultation We call your doctor usually within 1 to 3 hours.

$190.00

Invoice Hospital - 24 hours - $135Hospital will be invoiced the cost of the consultation at $135. Free ONLY means you will not be charged today.

$ Free

Invoice Hospital - ASAP - $190Hospital will be invoiced the cost of the consultation at $190. Free ONLY means you will not be charged today.

$ Free

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.

$210.00 Quantity

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

Direct Neurology Consultation Submission