Nancy Brock Veterinary Services - Telephone Consultation FORM
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Dr. Name: *
Clinic Name:
Clinic Address:
Clinic Phone #: *
Clinic Fax #:
Clinic Email:
Patient Name: *
 Owner Name:
Species:*
 Breed: *
 Age:*
 Sex:
 Weight (Kg)
Procedure Date (mm/dd/yy):
Procedure: *
Your Assessment of anesthesia risk (1=low, 5=high):
Medical History
Details of patient's previous anesthesia difficulties:
 Prior medical conditions which resolved:
Chronic or ongoing medical conditions:
 Current medication:
X ray/Ultrasound findings:
Abnormalities on physical examination:
Anesthesia Drugs  (you are familiar with and have ready access to):
Premedication:
 Induction:
Maintenance:
 Constant rate infusions:
Local nerve blocks:
Please list your anesthesia monitoring tools:
Your anesthesia will be monitored by:
Please fax copies of all relevant reports (e.g. lab, diagnostic imaging) to 1-866-315-7087 (toll free)