Telemedicine Consult Form Vet Hospital InformationVeterinarian Hospital Name Phone Email Client InformationName First Last Address Street Address City State / Province / Region ZIP / Postal Code Primary Phone Email Pet InformationPatient Name Breed Age Weight in KG Sex Male Neutered Male Unaltered Female Spayed Female Unaltered Referral InformationConsult Requested With Oncology Surgery Other Other Special Instructions Reason for Consultation Pertinent Medical HistoryCurrent MedicationsPlease include drug, strength, dosing instructions and date startedCompleted Diagnostics Radiographs Bloodwork Blood Pressure Ultrasound ECG Other Results of Previously Performed Diagnostics Other Materials - Please specify Please also submit the previous 6 months of medical records to records@VSRockies.com If you require a STAT consult, please call VSR at 303.660.1027 to speak directly with the appropriate specialist. Non STAT Consultations will be returned within 24 hours during normal business hours.NameThis field is for validation purposes and should be left unchanged. Δ
