Oncology Consultation - Colorado Animal Specialty & Emergency

Client Information

Patient Name

Client Name

Date of Birth or Approximate Age

Male
Neutered Male
Female
Spayed Female

Primary Phone

Email Address

Breed

Diagnosis or Presumed Diagnosis

Diagnosis or presumed diagnosis?

Diagnosis
Presumed Diagnosis

Diagnostics

Please have your family veterinarian send a copy of any diagnostics that have been performed emailed or faxed to Aspen Meadow Veterinary Specialists. They may be emailed to records@aspenmeadowvet.com or faxed at 303-678-8855. To better facilitate your appointment time, please have these emailed or faxed 24 hours before your appointment day

When was the most recent blood work/labwork/specialty labs (ie, FLOW cytometry)?

Have Xrays or CT scan been performed?

Yes
No

If so, please list body area.

Abdomen
Chest

Were they reviewed by a radiologist?

Yes
No

Has an abdominal ultrasound been performed?

Yes
No

Who performed the scan?

Radiologist
Internist
Family Veterinarian

Has a biopsy or cytology been performed?

Yes
No

History Questionnaire

When did symptoms first appear?

What were the symptoms noted?

Have symptoms improved, worsened, or stayed the same?

Worsened
Stayed the same

If worsened, or improved, please explain

Have any medications or treatments been initiated?

Yes
No

If so, did the patient respond once medications or treatments were initiated?

Please list any other supplements or medications that are being given.

Eating and drinking?

Normal
Increased
Decreased
Is not eating or drinking

Energy level

Normal
Increased
Decreased
Lethargic

Any Coughing, Sneezing, Vomiting or Diarrhea?

Is there anything special about your pet you would like us to know?

Please list any GOALS for your appointment:

Ie: pain control options, further diagnostics, information only, etc.

How did you choose us?

Primary Veterinarian

Consent*

I Agree

Payment must be rendered at time of service. We accept all major credit cards including Care Credit. Personal checks are welcome when accompanied by a driver’s license. If you have any questions regarding your payment, please discuss it with a receptionist before the start of your visit.

Name

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