Consultation Request

To request a client consultation, please fill out the patient case summary form below. For a mobile ultrasound and/or procedure, go to the Mobile Ultrasound and Procedure Request. If you have any questions regarding this form, please contact Dr. Nancy Treadwell, Shreveport Veterinary Internal Medicine at the phone/fax numbers below or email us at [email protected].

Email:	[email protected]
Contact SVIM at:	318-224-2677
Send a Fax:	1+ 318-301-6720

Time Frame: *

Emergency (call 318-224-2677 for availability))
Urgent (within 48 hours)
Routine

Request a Consult *

In-house consults are at your hospital or practice location. Telemedicine is online face to face in real-time discussion of case. Please email [email protected] to receive a price sheet and more details.

Is This a New or Follow-Up (Re-check) Consult? *

First Consult
Follow-up Consult

Requesting Veterinarian

Please provide all relevant contact information so that we may get in touch with you.

Requesting Veterinarian Name: *

First and Last Name

Veterinarian Email: *

Daytime Phone: *

After Hours Phone:

Mobile Phone:

Fax:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Client

Pet Owner / Caregiver

Client Name: *

First and Last Name

Client Email:

Client Phone:

Patient Information

Patient Name: *

Age: *

Species: *

Breed: *

Sex: *

Approximate Weight: *

Primary Reason for Consult:

Pertinent Medical History:

Pertinent Past Medical History:

Known Drug or Anesthetic Reactions: *

Medical records, x-rays and images relative to your patient case summary may be emailed to [email protected]

Email