Anesthesia and Pain Management Consultation Form Doctor's Name* First Last Email* Hospital Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxClient/Owner InformationOwner First Last PhonePatient InformationPet Name*Age*Breed*Gender* M F MC FS Weight (kgs)*Species* Canine Feline Ferrit Rabbit Bird Underlying Medical Problem* Cardiac Liver Renal GI Integumentary Pulmonary Endocrine Neurolic Current Problem for which consultation is required:List current drugs, nutraceuticals, doses, and frequency:Current problem with this therapy:Available Drugs* Acepromazine Atropine Alfaxalone Glycopyrrolate Xylazine Dexmedetomidine Propofol Ketamine Midazolam Diazepam Telazol Isoflurane Sevoflurane Dopamine Dobutamine Ephedrine Phenylephrine Epinephrine Norepinephrine Other If OtherMonitoring Equipment* Doppler Blood Pressure Oscillometric Blood Pressure (Dinamap, PetMAp) Invasive Blood Pressure ECG Pulse Oximeter Pulse Oximeter with PVI CO2 Monitor (Capnograph) Respiratory Monitor Available Injectable Analgesics* Morphine Oxymophone Hydromorphone Fentanyl Sufentanil Buprenorphine Long acting buprenorphine (Simbadol®) Buprenorphine SR Nalbuphine Methadone Xylazine Dexmedetomidine Carprofen Meloxicam Ketoprofen Lidocaine Bupivacaine NOCITA® Other If OtherAvailable Oral Analgesics* Regular Morphine Sustained Release Morphine Oxycodone Acetaminophen Acetaminophen with Codeine Codeine Deracoxib Ketoprofen Carprofen Firocoxib Piroxicam Aspirin Meloxicam Other If OtherWillingness to write prescription from pharmacy?* Yes No Classification of DEA license Schedule II drugs?* Yes No Select Consultation* Routine Consultations - $60 Phone Consultation - $75 STAT, evening, weekend consultations - $100 You will receive an email invoice from which you can pay by credit card upon receipt.Upload files here Drop files here or Select filesAccepted file types: jpg, pdf, jpeg, png, Max. file size: 256 MB.
