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?) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________