Consult Request Form

McDonnell Veterinary Neurology-Neurosurgery
Consult Request Form

**Please take a few moments to fill out the form and click send. A staff person will contact your hospital to get further information and to schedule the consult.

Form - Consult Request

Pet's Information

Name

Pet's Date of Birth

Sex (required) :

Altered :

Breed (mixed is OK): (required)

Coat Color

Weight (note kg or lbs): (required)

Client Information
First Name	Last Name

Client Phone Number (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's MEDICAL information

Previous Medical History (not associated with current problem) (required)

Present Complaint - Please include specifics: ie - can't walk and current medications (required)

Test(s) already perfomed (include all lab work and results) (required)

**Please fax JUST last year's medical record to our office at (443) 926-9666.

Clinic & Referring Vet Information

RDVM (Referring Vet): (required)

Clinic Name (required)

RDVM Phone Number: (required)

RDVM E-Mail Address (required) :

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