Orthopedics Consult Form

This service is for veterinarians only – clients seeking medical information should contact their regular veterinarian for assistance.

You are submitting a Consult to the Small Animal Orthopedic Service. We will do our best to respond as soon as possible. This will generally be within 48-72 hrs of submission. If you have not had a response within that time, please call the Service directly. Because consults are often addressed at the end of the day, please provide contact information for the late evening, if possible.

What is your preferred contact method?(Required)

By Phone

By Email

Best hours to contact

Veterinarian Contact Information

Veterinarian to contact(Required)

Clinic(Required)

Clinic Phone Number and / or Alternate Contact Number(Required)

Clinic Fax Number

Clinic Email

Owner Contact Information

Name of the owner

First Last

Owner Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Owner Email

Information about the patient

Has this patient ever been seen by any service at NC State Veterinary Hospital?

Yes

No

Not Sure

Patient/Pet Name

First

Species(Required)

Dog

Cat

Equine

Exotic Animal

Date of Birth or Age

MM slash DD slash YYYY

Breed

Weight (please specify lbs or kgs)

Color

Gender

M

MC

F

FS

Reason for consult

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Raleigh, NC 27607

919.513.6500

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