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518.783.3199

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Home » Pre-Consult Form: Oncology

Pre-Consult Form: Oncology

Oncology Pre-Consult Form

Client Information
Date*
MM slash DD slash YYYY
Client Name*
First Last
Patient Name*
First Last
Email*
Phone
Alternate Contact
First Last
Email
Phone
Ideal Pick Up Time*
Client History
Overall, how has your pet been doing since we last say them?*
Has your pet experienced any lethary, reduced energy, or is sleeping more?*
- Yes
- No
If yes, please explain:
Has your pet had any coughing?*
- Yes
- No
If yes, how often?
Has your pet been sneezing?*
- Yes
- No
Has your pet experienced any diarrhea or soft stool?*
- Yes
- No
If yes, how many days?
Did you administer Metronidazole (Flagyl)?
- Yes
- No
If yes, how many doses?
Have any other supportive interventions been used? (Clay, Powder etc.)
- Yes
- No
If yes, please describe:
Has the diarrhea resolved?
- Yes
- No
Has your pet experienced any nausea or vomiting?*
- Yes
- No
If yes, how many days?
Did you administer Zofran?
- Yes
- No
If yes, how many doses?
Did you administer Cerenia?
- Yes
- No
If yes, how many doses?
Has the nausea or vomiting resolved?
- Yes
- No
How well is your pet eating?*
When did your pet eat last?*
What medications is your pet currently receiving?*
Please check all that apply:
- Prednisone
- Pepcid (famotidine)
- Omeprazole
- Zofran
- Metronidazole (Flagyl)
- Cerenia
- Piroxicam
- Probiotic
- Mirtzazpine
- Palladia
Do you need any refills on medication?*
- Yes
- No
If yes, please specify:
Please add any additional comments or requests here:

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Hours of Operation

Specialty Services: Monday – Friday 8am-6pm
*Subject to change during Holidays

Emergency Service: 24 hours a day / 7 days a week

Upstate Veterinary Specialties, PLLC

152 Sparrowbush Road, Latham, New York 12110
Phone: 518.783.3198 Fax: 518.783.3199

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