Vet-to-Vet Medication Consultation Form "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.General Information & Medical HistoryClinic name*Veterinarian’s name*Referring veterinarian role* Patient’s primary care vet Specialist Other If specialist, please note specialty*If other, please describeHow did you hear about us?Has the pet had baseline blood work (CBC, chemistry) performed within the past year?* Yes No Date of last blood work*Any abnormal results*Current medications, supplements, or other treatments*Name, formulation, dose (mg)Frequency (e.g. Q24, PRN)Clinical effect and side effects Add RemoveHas the pet previously been prescribed medications, supplements, or pheromones for behavior not listed above?* Yes No If yes, list name, dates, dose, effect, and why it was discontinued*Any chronic medical conditions?* Yes No Chronic medical conditions details*Any current or history of pain (limping, difficulty getting up or lying down, resistance using stairs, etc.)?* Yes No Pain details*Any appetite concerns?* No Excessive Good/Average Poor Appetite detailsBasic Pet InformationPet’s name*Signalment*Include species, breed, sex, age, and any other relevant details.Weight (kilograms)*Does the pet have signs of generalized anxiety disorder?For example: easily startled by subtle noises, difficulty settling in the home, etc.Current Behavior ProblemsDescribe the main behavioral concerns for the pet that prompted the consultation*Is this consultation specifically for assistance with pre-visit medications?* Yes No Veterinary Visit AnxietyPatient’s Fear-Anxiety-Stress Score FAS 2 FAS 3 FAS 4 FAS 5 What has been attempted?For example medications/supplements/pheromones not already listed above, specific entrance protocol, specific room setup, adjusted staff interactions, training protocols/working with a specific trainer, sedation.Have any previous interventions been effective? Which ones?Any notable factors that increase the patient’s stress?For example, pet parent’s absence, seeing other patients in the lobby, specific staff members, etc.Future ConsiderationsWhat are the client’s goals for treatment?*Additional commentsPlease leave any comments about the form or information that did not fit in any other section.
