Veterinary Telemedicine Consultation Form

Veterinary Telemedicine Consultation Form
Fill out this form to request a consultation for your patient. If you have not called our office to set up an account, please do so before submitting the consult form. For more information on consults, go here: https://www.flvetbehavior.com/veterinary-telemedicine-consults.html. Don't forget to upload medical records and videos. Included in the telemedicine consult is up to 4 minutes of videos. Any time over 4 minutes of videos will incur an additional charge.
Hospital and Doctor
Hospital*
Referring Doctor*
Hospital account number
Best email for Doctor/Hospital*
Client
Client Name*

First Name Last Name
Patient
Patient Name*
Species*

CanineFelineAvian
Weight in pounds*
Breed*
Date of Birth

MonthDay Year
Date
Or Age in years
Gender Status*

Male intactMale neuteredFemale intactFemale spayed
Behavioral History

Fill out the form below.

For the doctor to best help your patient, do not copy and paste a narrative from the pet parent or send additional emails from them. Instead, summarize the clinical signs and history that was provided by the pet parent.

Presenting Compliant

	Age when started	Frequency
Aggression
Anxiety
Fear
Fly Snapping
Elimination in the house
Leash Reactivity
Litterbox issues
Noise phobia
Separation anxiety
Storm phobia
Tail chasing
Run in circles

Additional problems not listed above which you would like considered
Situations in which aggression is exhibited. Check all that apply.

BathedBrushedSees bikesCollar taken off/put onCorrectedEatingEyes wipedExamined by veterinarianGroomed (professional groomer)Has a boneHas foodHuggedIn carIn his bedIn your bedIn the houseItem is droppedOn walksIn the yardLeash put on/taken offLiftedLooked atNails trimmedPlayingPushed/pulledReached forSpoken toTouchedSees kidsSees/hears motorcycleSleepingWhen startledToweled
If Patient has bitten, number of bites

1-23-5>5
Targets of aggression. Check all that apply.

Familiar adultsUnfamiliar adultsVeterinarianFamiliar dogsUnfamiliar dogsFamiliar childrenUnfamiliar childrenGroomerFamily catWild animals outside of the homeCats outside of the home
Aggression clinical signs. Check all that apply.

Bare teethBarkBite (mouth contacts victim, no broken skin)Bite (mouth contacts victim, skin broken)ClawDilated pupilsEars backGlassy eyedGrowlHead downHair up on back (piloerect)HissLick lipsLower bodyLungePantRear up on hind legsScratchSnapping-Opening and closing of mouth, no contact to victimStiff bodySwatTense musclesTail over backTuck tailTurn head awayTry to get awayWag tailYawnZones outPatient doesn't exhibit any of these clinical signs
Storms/Sounds

If your patient exhibits fear or anxiety during storms or loud noises please fill out this section. If not, go to the next section.
Triggers

Electronic beepingConstructionThunderLarge truck soundsFood sizzling in a panText alert sound
Clinical Signs

PantsPacesHyper salivates (drools)Acts aggressively if you try to move himTremblesHowlsBarksComes to find youDestructive
Recovery

Immediately10 minutes10-20 minutes20-30 minutes30-40 minutes40-50 minutes50-60 minutes1-3 hours3-6 hours6-12 hours12-24 hoursGreater than one day
Separation Behaviors

If your patient exhibits anxiety or distress when left alone please fill out this section. If not, go to the next section.
Clinical signs

TrembleHideAttempts to escapeDestroyBarkHowlWhineTries to escape the crateUrinateDefecate
Does the patient exhibit the behavior every time that the pet parent departs?

YesNo
Does the patient exhibit the behavior only when alone?

YesNo
Displacement/Compulsive behaviors

If your patient exhibits any of the behaviors below, please fill out this section. If not, go to the next section.
Anxiety/Fear

HypersalivationPacingPantingDestructionAttempts to HideAttempts to find the ownerClimbing on top of furnitureUrinationDefecationVomitingReluctance to eatHowlsBarksDepressionPatient doesn't exhibit any of the above clinical signsUnknown
Situations

Owner departureStormsFireworksElectronic soundsGoing outsideCarLeashParticular person
For cats only

For behavioral periuria consultations pictures or videos of the litterboxes and their locations must be submitted.
Elimination behavior (check all that apply)

Urination outside of the litterboxLarge amountsVertical surfacesSmall amountsHorizontal surfacesStanding to urinate with tail twitchingCurved body postureMeows when leaves boxTries to cover in boxTries to cover outside of boxLarge amounts of feces outside of the boxSmall amounts of feces outside of the boxPatient doesn't exhibit any of the above clinical signsUnknown
Situations (check all that apply)

Owner is homeOwner is not homeSoft surfacesHard surfacesHigh surfacesLow surfaces
Number of cats in household
Number of litterboxes in household
Type of litter
Other body systems

Changes in overall health have a major impact on behavioral clinical signs. Make sure to check all that apply and use the "other" field if necessary.
Other body systems

Changes in appetiteWeight lossWeight gainMuscle wastingOrthopedic painChronic otitis externaChronic pyodermaPruritusNeurologic painChanges in defecation (diarrhea, constipation)Recurrent urinary tract infectionsChanges in urination (frequency, location, pain)The patient has none of the changes listed aboveEndocrine (diabetes, Cushing's, Addisons, hypothyroidism
Medical treatments

Your patient's medical records including images will be reviewed. If your patient has been on a medication or supplement which is not listed in the medical record, please add it below.
Current Medications (list all) To be filled out by veterinarian/veterinary technician*
Medical history (Master diagnosis list) Please list current and past diagnoses. To be filled out by veterinarian/veterinary technician.*
Private comments for the veterinary behaviorist
When treating veterinary behavior (psychiatric) cases, aggression is often a clinical sign. There is inherent liability in treating these cases. Your consultation is based on the information provided here and is not as complete as an appointment with the veterinary behaviorist. Take the time to read about the medications and treatments recommended so that you can make the best decisions for your patient. FVBS is not responsible for the outcomes of the cases for which we consult. Please read and sign to acknowledge that you understand and agree to the above statements. Your patient's consulation cannot be completed without a signed waiver.
Signature (Use your track pad and sign with your finger or use your mouse)*

Clear
e-Signature*

First Name Last Name
Before you go..don't forget to go to https://www.flvetbehavior.com/veterinary-telemedicine-consults.html to upload your patient's videos
Should be Empty:

Veterinary Telemedicine Consultation Form

Hospital and Doctor

Client

Patient

For cats only

Other body systems

Medical treatments

Before you go..don't forget to go to https://www.flvetbehavior.com/veterinary-telemedicine-consults.html to upload your patient's videos