Vet to Vet Online Consult History

VET TO VET TELEHEALTH HISTORY FORM
READ THIS FIRST!

Yea! You have decided to help your patients with behavior problems! You are awesome!

There are four steps to submitting a consult. Follow the steps below to get your consult back as fast as possible.
1. Create an account. If you have already done this, great! If not, you can create an account here.
2. Fill out a consult history form, You are in the right place to complete this step.
3. Upload 2-4 videos (total of no more than 4 minutes of video) nd medical record in the consult form. You can save the form and work on it later if you need to do so.
4. Pay for your patient's consult within the history form (you are here!). Just enter your credit card number.
When we receive all documents above and payment, Dr. Radosta will process your patient's consult within 2 business days.

If you have questions, contact us at: vetbehavior911@gmail.com

***Consults are processed Tuesday-Thursday.***
Hospital and Veterinarian
Hospital*
Referring Doctor*
Best email for Doctor/Hospital*
Best Phone Number for Doctor/Hospital*

Area CodePhone Number
Client
Client Name*

First NameLast Name
Patient
Patient Name*
Species*

CanineFelineAvian
Weight in pounds*
Breed*
Age in years
Gender Status*

Male intactMale neuteredFemale intactFemale spayed
Clinical Signs

Presenting Compliants

	Age of onset	Frequency
Aggression
Anxiety
Fear
Fly Snapping
Elimination in the house
Leash Reactivity
Litterbox issues
Noise phobia
Separation anxiety
Storm/Noise phobia
Tail chasing
Run in circles

List the two most important problems to be addressed. This way, I can make sure to address those completely.
Aggression

If your patient exhibits aggression please fill out this section. If not, go to the next section.
How old was your pet when you first noticed the aggression?

Before 1 year1-3 years3-7 years8+ years
Situations in which aggression is exhibited. Check all that apply.

BathedBrushedSees bikesCollar taken off/put onCorrectedEatingEyes wipedExamined by veterinarianGroomed (professional groomer)Has a boneHas foodHuggedIn carIn his bedIn your bedIn the houseItem is droppedOn walksIn the yardLeash put on/taken offLiftedLooked atNails trimmedPlayingPushed/pulledReached forSpoken toTouchedSees kidsSees/hears motorcycleSleepingWhen startledToweledOther
If Patient has bitten, number of bites

1-23-5>5
Targets of aggression. Check all that apply.

Familiar adultsUnfamiliar adultsVeterinarianFamiliar dogsUnfamiliar dogsFamiliar childrenUnfamiliar childrenGroomerFamily catWild animals outside of the homeCats outside of the homeOther
Aggression clinical signs. Check all that apply.

Bare teethBarkBite (mouth contacts victim, no broken skin)Bite (mouth contacts victim, skin broken)ClawDilated pupilsEars backGlassy eyedGrowlHead downHair up on back (piloerect)HissLick lipsLower bodyLungePantRear up on hind legsScratchSnapping-Opening and closing of mouth, no contact to victimStiff bodySwatTense musclesTail over backTuck tailTurn head awayTry to get awayWag tailYawnZones outPatient doesn't exhibit any of these clinical signsOther
Storms/Sounds

If your patient exhibits fear or anxiety during storms or loud noises please fill out this section. If not, go to the next section.
How old was your pet when you first noticed the fear of sounds?

Before 1 year1-3 years3-7 years8+ years
Triggers

Electronic beepingConstructionThunderLarge truck soundsFood sizzling in a panText alert soundOther
Clinical Signs

PantsPacesHyper salivates (drools)Acts aggressively if you try to move himTremblesHowlsBarksComes to find youDestructiveOther
Recovery

Immediately10 minutes10-20 minutes20-30 minutes30-40 minutes40-50 minutes50-60 minutes1-3 hours3-6 hours6-12 hours12-24 hoursGreater than one dayOther
Separation Behaviors

If your patient exhibits anxiety or distress when left alone please fill out this section. If not, go to the next section.
How old was your pet when you first noticed that your pet was stressed when alone?

Before 1 year1-3 years3-7 years8+ years
Separation related behaviors

Attempts to HideAttempts to find personBarksCan't be crated/confinedClimbing on top of furnitureDefecationDepressionDestructionHowlsHypersalivationPacingPantingReluctance to eatTremblingUrinatingVomitingWhiningOther
Does the patient exhibit the behavior every time that the pet parent departs?

YesNo
Does the patient exhibit the behavior only when alone?

YesNo
Displacement/Compulsive behaviors

If your patient exhibits any of the behaviors below, please fill out this section. If not, go to the next section.
How old was your pet when you first noticed the behavior?

Before 1 year1-3 years3-7 years8+ years
Displacement/compulsive

Fly snappingLight chasingPicaShadow chasingOther
For cats only

For behavioral periuria consultations pictures or videos of the litterboxes and their locations must be submitted.
Elimination behavior (check all that apply)

Urination outside of the litterboxLarge amountsVertical surfacesSmall amountsHorizontal surfacesStanding to urinate with tail twitchingCurved body postureMeows when leaves boxTries to cover in boxTries to cover outside of boxLarge amounts of feces outside of the boxSmall amounts of feces outside of the boxPatient doesn't exhibit any of the above clinical signsUnknownOther
Situations (check all that apply)

Owner is homeOwner is not homeSoft surfacesHard surfacesHigh surfacesLow surfacesOther
Number of cats in household
Number of litterboxes in household
Type of litter
List any additional problems that you would like addressed.
Other body systems

Changes in overall health have a major impact on behavioral clinical signs. Make sure to check all that apply and use the "other" field if necessary.
Other body systems

Changes in appetiteWeight lossWeight gainMuscle wastingOrthopedic painChronic otitis externaChronic pyodermaPruritusNeurologic painChanges in defecation (diarrhea, constipation)Recurrent urinary tract infectionsChanges in urination (frequency, location, pain)The patient has none of the changes listed aboveEndocrine (diabetes, Cushing's, Addisons, hypothyroidismOther
Medical treatments

Your patient's medical records including images will be reviewed. If your patient has been on a medication or supplement which is not listed in the medical record, please add it below.
Current Medications (list all) *
Medical history (Master diagnosis list) Please list current and past diagnoses. *
Additional history
***PLEASE DON'T SKIP THIS STEP***

Upload 2-4 videos (total of no more than 4 minutes of video) and medical record below.

Your patient will receive a better evaluation and plan if your client submits videos.

If you would like a separate link for the videos so that clients can submit them directly instead of dropping them into this form:

https://www.dropbox.com/request/pI2w3pXbf6Bq1uDjR9Uq
Dr. Radosta often teaches veterinarians healthcare team members, pet parents and dog trainers on the behavior of animals. We would like permission to use those videos for any lawful purpose, including, but not limited to, website, social media accounts, and promotional materials, either digital or in print, in perpetuity. By selecting yes, below, I authorize Dr. Radosta to edit, alter, share, remix, tweak, build upon or in any way alter the photographs or videos mentioned above. I also waive any rights of privacy or compensation associated with the use of my or my pet’s image(s) and name(s) for the personal or commercial purposes outlined above.*

Yes, I consentNo
SUBMIT MEDICAL RECORDS AND VIDEOS HERE*

Browse Files

Cancelof

Pay for your consult here.

Full Veterinarian to Veterinarian Telehealth Consultation $300.00

What you get: A 2-4 page report with an assessment of your patient's behavior; differential diagnosis list; initial medication, management and safety and behavior modification plan. Follow up questions regarding the initial consultation via email (vetbehavior911@gmail.com) for up to 14 days after the consult is returned to you at no additional cost.

Total $0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

When treating veterinary behavior (psychiatric) cases, aggression is often a clinical sign. There is inherent liability in treating these cases. Your consultation is based on the information provided here and is not as complete as an appointment with the veterinary behaviorist. Take the time to read about the medications and treatments recommended so that you can make the best decisions for your patient. Dr. Radosta is not responsible for the outcomes of the cases for which we consult. Please read and sign to acknowledge that you understand and agree to the above statements. Your patient's consulation cannot be completed without a signed waiver.
Signature (Use your track pad and sign with your finger or use your mouse)*

Clear
e-Signature*

First NameLast Name
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VET TO VET TELEHEALTH HISTORY FORM

Hospital and Veterinarian

Client

Patient

Clinical Signs

For cats only

Other body systems

Medical treatments