Coastal Rivers Pet Hospital
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Tele-medicine History Form

Telemedicine Consultation History Form ​

Remember to also fill out the Tele-medicine Consent Form
Coastal Rivers Pet Hospital Telemedicine Consultation History Form 
(Available during the COVID-19 Pandemic only.) 

Instructions: 
  • Please complete this form and return it by email (scan) or photo to [email protected] along with your Telemedicine Waiver form. 
  • The consultation fee may be paid by credit card phoned into our Reception Team prior to the start of your consultation. 
  • At the time of payment, the receptionist will schedule your consultation time with a veterinarian. 

Pet Information: 
Name: ___________________________     

Date of Birth: MM ___/DD___/YYYY_______ 

Species: _______________ Breed: ____________________ 

Weight: _______________ 

Sex (circle one): intact female; spayed female; intact male; neutered male 

Current Medical Concern: (what is causing your primary concern regarding your pet right now?) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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  • Home
  • About
    • About
    • Policies
    • Dr. Borgmann
    • Dr. Taylor
    • Dr. Lawrence
    • Dr. Fritz
    • Dr. de Jong
  • Services
    • Services
    • Surgery Dentistry Radiology Endoscopy
    • Orthopedic Surgery
    • Rehabilitation >
      • Stance Analyzer
      • Therapeutic LASER
      • Underwater Treadmill
      • Regenerative Therapy PRP and BMAC
    • End of Life
  • Contact
    • Contact
    • Book your appointment on line
    • Prescription Renewal Form
    • New Client Form
    • Petly Pages
  • Emergencies
  • New Client Form