Neurology Consult Form

This service is for veterinarians only – clients seeking medical information should contact their regular veterinarian for assistance.

This information will be routed to the Service that you request. We will do our best to respond as soon as possible. If you have not had a response within five business days, please call the Service directly. Because consults are often addressed at the end of the day, please provide contact information for the late evening, if possible.

What is your preferred contact method?(Required)

By Phone

By Email

Best hours to contact(Required)

Veterinarian Contact Information

Veterinarian to contact(Required)

Clinic(Required)

Clinic Phone Number and / or Alternate Contact Number(Required)

Clinic Fax Number

Clinic Email(Required)

Owner Contact Information

Name of the owner(Required)

First Last

Owner Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Owner Email(Required)

Information about the patient

Has this patient ever been seen by any service at NC State Veterinary Hospital?(Required)

Yes

No

Not Sure

Patient/Pet Name(Required)

First

Species(Required)

Dog

Cat

Equine

Exotic Animal

Date of Birth or Age(Required)

MM slash DD slash YYYY

Breed(Required)

Weight (please specify lbs or kgs)(Required)

Color(Required)

Gender(Required)

M

MC

F

FS

Reason for consult(Required)

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Raleigh, NC 27607

919.513.6500

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