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Oncology Services
Telemedicine Services
At-Home Visits / Mobile Care
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About
About VCCS
Our Team
FAQs
How it Works
Client Resources
Client Intake Form
Resources & Guides
Referrals and Professional Recommendations
Clinical Trials
Referring Vets
Contact
Oncology Services
Telemedicine Services
At-Home Visits / Mobile Care
Primary Veterinary Support
About
About VCCS
Our Team
FAQs
How it Works
Client Resources
Client Intake Form
Resources & Guides
Referrals and Professional Recommendations
Clinical Trials
Referring Vets
Contact
Request Consultation
VCCS Consultation Intake Form
Please take the time to complete all fields on our Consultation Intake Form. Use the “save and continue” option to save your progress for up to 30 days.
VCCS History Intake Form
1
Personal Details
2
Veterinarian Details
3
Medical History
4
Lifestyle Details
5
Goals
6
Billing
Client Details
Client First Name
Client Last Name
Email
Phone Number
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Pet Details
Pet’s Name
Pet’s Breed
Pet’s Sex
Female spayed
Male castrated
Female intact
Male intact
Unsure/Other
Pet’s Date of Birth
MM slash DD slash YYYY
Please list all veterinary hospitals your pet has been to (including recent and past visits).
Use the “+” icon to add additional rows.
Hospital Name
Veterinarian(s) Involved
Phone Number
Email
Add
Remove
If possible, please upload all medical records for each veterinarian your pet has seen over the past year, as well as any records relating to a past or current diagnosis of cancer.
[NOTE: Types of records include: medical notes, bloodwork and urine test results, cytology and biopsy reports, images, ultrasound and/or x-ray (radiology) reports, and outside lab test results]
Drop files here or
Select files
Max. file size: 50 MB.
What is your pet's diagnosis?
Has this diagnosis been confirmed with a tissue sample?
(such as a fine needle aspirate/cytology or biopsy)
Yes
No
Please describe your pet's CURRENT medical history.
This includes an explanation of what is going on with your pet, what prompted you to bring your pet in to see a veterinarian, and/or what led to getting this diagnosis.
Please describe your pet's PAST medical history.
This includes any illness, diseases, conditions, episodes of hospitalizations, past surgeries, or past diagnosis(es) of cancer.
List of CURRENT medications:
(include supplements and vitamins here)
Use the + icon to add additional rows.
Medication/Supplement
Dosage and Frequency
Add
Remove
List of PAST medications:
(include medications given intermittently at home on an as-needed basis)
Use the + icon to add additional rows.
Medication/Supplement
Dosage and Frequency
Add
Remove
Please note any reactions to medications here:
What is your pet's regular diet?
Is your pet currently eating this diet?
Yes
No
What you are feeding your pet?
Appetite:
Normal
Abnormal
Describe Abnormal Appetite:
Energy Level:
Normal
Abnormal
Describe Abnormal Energy Level:
Vomiting:
Yes
No
Describe Vomiting:
Diarrhea:
Yes
No
Describe Diarrhea:
Coughing:
Yes
No
Describe Coughing:
Sneezing:
Yes
No
Describe Sneezing:
Change in drinking:
More
Less
Normal
Describe drinking:
Change in urinating:
More
Less
Normal
Describe urinating:
Other symptoms not listed:
Yes
No
Describe other sympotms:
What are your goals for your pet and what would you like to get out of the consultation?
Please select all that apply:
I would like to get more information about my pet's cancer/diagnosis before making a decision about treatment
I would like to start treatment as soon as possible
Cost is a big factor in my decision to treat, and I will need detailed estimates to determine if treatment is possible for my pet
My pet is very nervous/aggressive and I am worried about multiple office visits
I would prefer someone to come to my home for treatment
I am not interested in treating my pet's cancer with chemotherapy or anticancer therapies, but I would like to focus on how to keep my pet comfortable
Other
Please describe.
I have pet insurance
Yes
No
Name of insurance company?
Do you give us permission to share our records with your primary or referring veterinarian(s) after the consultation is completed? Yes/No (if yes, please list which veterinarians you would like us to share records with)
Do you give us permission to share our records with your primary or referring veterinarian(s) after the consultation is completed? Yes/No (if yes, please list which veterinarians you would like us to share records with)
I give permission.
Do you give us permission to share our records with your primary or referring veterinarian(s) after the consultation is completed?
Yes
No
Please list which veterinarians you would like us to share the records with:
Please fill out this form if you wish to pay for the consultation by credit card; if you prefer other methods of payment (Zelle, Venmo, Check, Cash) please check the box below and contact us directly for your preferred method of payment.
Please note, we will not be able to proceed with the consultation until payment is received. If payment is not received by the time the appointment starts, the consultation will be canceled and rescheduled for a later time.
Payment Options:
Pay Now
Pay Just Prior to Appointment
I wish to pay for the consultation by an alternative method of payment.
Yes, I will contact you directly with my preferred method of payment.
My billing address is the same as my home address.
Yes
Billing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credit Card
Cardholder Name
Card Details
Consultation Fee
Price:
Consent
I give VCCS permission to charge my credit card directly for the consultation.
I agree.
CAPTCHA
Complete the Sentence: what goes up must come...
Email
This field is for validation purposes and should be left unchanged.
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