EMERGENCY
| 780-570-9999
Submit a Referral
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Submit a Referral
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Home
About
Meet Our Team
Careers
Contact
Departments
Cardiology
Anesthesiology
Dentistry & Oral Surgery
Diagnostic Imaging
Emergency and Critical Care
Internal Medicine
Neurology
Ophthalmology
Surgery
Pet Owners
What To Expect
Referral Process
Pet Admission Forms
FAQ
Submit a Request for an OFA Exam
Veterinarians
Submit a Referral
Continued Education
Testimonials
EMERGENCY
| 780-570-9999
Submit a Referral
Neurology Questionnaire
Neurology Questionnaire
Step
1
of
2
50%
Date
*
MM slash DD slash YYYY
Client Information
First and Last Name
*
Primary Phone Number
*
Email Address
*
Do you have medical insurance for your pet?
*
Yes
No
What company is it with?
*
Patient Information
Pet Name
*
Date of Birth
*
MM slash DD slash YYYY
Breed
Gender
*
F
FS
M
MN
Is your dog a working-dog?
*
Yes
No
What type of work?
*
Please explain
Do you consent to having your pet included in educational and promotional material used on websites, social media and in professional presentations? This could include photographs, diagnostic images, patient medical information, and pet's first name.
*
Yes
No
Presenting Problem
In a few sentences, please indicate the reason for the Neurology consultation (your understanding of why you are coming in).
*
What were the first signs you noticed?
*
When did you first notice these signs?
*
What testing has been done with your primary veterinarian?
*
What treatments have been tried with your primary veterinarian?
*
Has there been any change to the signs (unchanged, improved, worsened; over what timeline)?
*
Is your pet on any medication?
*
Yes
No
If yes, please list ALL medications your pet is currently taking (Please include the name(s) of medication, tablet/capsule size/strength or liquid concentration, amount given, and how frequently it is administered).
Do you have a video of the concerns? If so, please upload below
*
Video/Image (max 50MB)
Drop files here or
Select files
Accepted file types: jpg, png, pdf, mov, mp4, avi, webm, flv, mkv, Max. file size: 50 MB.
What are your goals of this consultation appointment?
*
Consultation and management options
Consultation and further diagnostic workup (MRI/advanced imaging, possible spinal tap, etc.)
Unsure
Additional Medical History
Is your pet up to date on vaccinations?
*
Yes
No
Unsure
Is your pet up to date on prevention (flea, tick, etc)? If so, which medications and when did they receive them?
*
Does your pet go outdoors?
*
Yes
No
Is your pet supervised outdoors?
*
Yes
No
Occasionally
Is there any access to standing water, wildlife, cattle, raw organs/carcasses?
*
Has your pet travelled outside of the province recently? If so, where and when?
*
Do you have any other pets in the household? If so, what breeds and do they have any current medical conditions?
*
*FELINE PATIENTS ONLY* - Do you know their FeLV/FIV status?
Does your pet have any known allergies? If so, what are they?
*
What is your pets current diet?
*
Any additional information or concerns?
Name
This field is for validation purposes and should be left unchanged.
