Teleconsultation Questionnaire

Teleconsultation Questionnaire
In order to provide the most useful and detailed discussion during our video consultation, please provide the following information regarding the patient you are contacting us to discuss.
Consultation Overview
Your Name*

First NameLast Name
What is the name of your practice?*
Your Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What are the reasons you/your client are seeking a SAIM teleconsultation and what are your goals for the consultation?*
Please provide the patient's signalment (i.e. age, sex, neuter status, species, breed).*
Patient History & Concerns
What are the patient's presenting complaints/concerns?*
Please provide a summary of the patient’s current history and medical concerns.*
Please list the patient's previous medical concerns.*
Please list any current medications the patient is receiving, including dosages (in mg/kg) and frequency of administration.*
Please provide the patient's physical examination findings including body weight and body condition score.*
Medical Files
Please upload all diagnostic test results.

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Please upload all imaging reports and original images.

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Please upload the patient's complete medical records.

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Should be Empty: