Pain Management Consult Form

Your Email(Required)

What is your preferred contact method?(Required)

By Phone

By Email

Best hours to contact

Do we have your permission to ask your receptionist to interrupt you if you are with a client?(Required)

Yes

No

Veterinarian Contact Information

Veterinarian to contact(Required)

Clinic/Hospital(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?

Yes

No

Not Sure

Patient/Pet Name(Required)

First

Date of Birth or Age

Breed

Weight (please specify lbs or kgs)

Gender

M

MC

F

FS

Pertinent medical summary(Required)

Specific questions to be addressed(Required)

Upload File(s) of Patient's Medical Records(Required)

Drop files here or

Max. file size: 195 MB.

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Raleigh, NC 27607

919.513.6500

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