If you are a practicing veterinarian and you would like consultation on a case, please completely fill out the following information and Dr. Hanson will respond as quickly as possible. Thank you.
 
Referring Veterinarian Information
  Name   Phone ex. 123-456-7890
  Hospital   Fax ex. 123-456-7890
  Address   Email
         
  City   State Zip
           
Client Information
  Name   Home Ph ex. 123-456-7890
  Address   Work Ph ex. 123-456-7890
         
  City   State Zip
           
           
Patient Information
  Name   Date of Birth ex. mm/dd/yyyy
  Breed   Sex Male Female
  Weight lbs.     (please check one)
   
Additional Information
Presenting Complaint:
   
Other Pertinent Medical Conditions:
   
Current Medications (including doeses):
   
Past Medications for the Presenting Complaint:
   
Diagnostic Tests Completed and Results:
   
Additional Comments