Online Consultancy Request Form

Avian and Exotics Consultancy Service

3 Oelkers Crt
Hodgsonvale, Queensland 4352

(614)189-8720 x2

www.avianandexoticsconsultancyservices.com

Note: This form will not save text and uploaded files until it is submitted. Please ensure that you complete the form in a single session or use the paper based form.

Online Consultancy Request Form

Name of Veterinarian: (required)

Practice Administrator / Billing Contact Person (required)

Email Address or Fax Number for Billing (required)

Veterinary Practice (required)

Veterinary Practice Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Veterinary Practice Phone (required)
Phone TypePhone Number (required)
E-Mail Address for Reports :
How would you like us to respond?

Email
Phone


Patient Information
Pet's Name

Owner's Last Name

Species

Age in years

Breed

Sex

Weight in g 

Diagnosis

CBC, Chemistry Profile, UA performed? 

Other blood tests? 

Radiographs?

Ultrasonography? 

Any other imaging?

Current drug therapy and/or response to previous medications? 

Other pertinent medical history? 

Additional comments or specific questions? 

Please send a copy of biopsy/cytology report to:
Please provide a summary of pertinent details including clinical signs, duration, etc. If sending the medical record, please also include a summary to orient us to the cancer problem.

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