Please fill out and submit this form with pertinent test results and reports; any reports that cannot be pasted in can be sent by fax to +61 (2) 6586 1210.

Please note, pressing "Enter" sends the form; so "Tab" or mouse-click to advance to the next field.

We will report back to you by the end of our next consulting day (Monday - Thursday, 8 am – 3 pm, New South Wales, Australia time) by your preferred method (phone, fax, or email). We will send you a tax invoice at the end of the month.

We look forward to working with you!

    Please provide the following contact information:

Name of Veterinarian
Practice Contact Person for Billing
Veterinary Practice
Street Address
Address (cont.)
City
State/Territory
Postal Code
Country
Phone Number
Fax
E-mail

    How would you like us to respond?

Email ($125)
Fax ($125)
Phone ($135)

          (Follow-up consultations for ongoing case management - $25)

    Do you need:

Chemotherapy protocol ($25) (if custom-designed, $50)
 Information on drug handling and administration ($15 each)
 

    Would you like to receive additional information?

Abstracts of pertinent literature ($50)
 Client information sheets on treatment type and protocol ($15 each)
 Client information sheet on tumour type and behaviour ($15)

    Patient information

Pet's Name
Owner's Last Name
Species
Age in years
Breed
Sex Male Female Male desexed Female desexed
Weight in kg

    Diagnosis (please paste in or fax a copy of biopsy/cytology report)

    Cancer History (include tumour location, size, duration, etc.)

    CBC, Chemistry Profile, UA performed?


    Other blood tests?


    Regional lymph node evaluation?


    Bone marrow evaluation?


    Radiographs?


    Ultrasonography?


    Any other imaging?


    Current drug therapy and/or response to previous medications

    Other pertinent medical history

    Additional comments or specific questions