Request Advice | NW Specialists

Owner details

Name*

Address*

Telephone number*

Mobile number

Email*

Insured?*

Yes

No

If yes, which insurance company?

Practice details:

Referring Vet Name*

Address*

Telephone number*

Mobile number

Email*

Preferred contact for reports*

Email

Post

Patient details

Name*

Age/DOB*

Breed*

Species*

Weight*

Sex*

Male

Female

Neutered

Brief summary of presenting complaint/reason for referral*

Diagnosis

e.g. Idiopathic epilepsy

Investigations performed to date

Investigations performed and results that helped to reach the diagnosis (Please send the results of the investigations performed in a separate document attached):*

Attachments*

Drop files here or

Max. file size: 20 MB.

Concomitant diseases and treatments*

Current medical treatments/medications (doses must be expressed in mg/kg and frequency e.g. phenobarbital 3 mg/kg BID):

Name of the drug

Date of treatment commencement

Date of last dose change

Current dose and frequency

Last anti-epileptic drug serum concentration results (please specify the unit (e.g. mg/dl) and send us the results in a separate file attachment):

Phenobarbital serum concentration result

Date performed

Docment attached

Document attached

Potassium bromide serum concentration result:

Date performed

Docment attached

Document attached

Levetiracetam serum concentration result

Date performed

Docment attached

Document attached

Zonisamide serum concentration result

Date performed

Docment attached

Document attached

Haematology and serum biochemistry performed?*

Attachments*

Drop files here or

Max. file size: 20 MB.

Seizure activity in the last 6 months:

Month

Number of seizures

Number of clusters (cluster = more than one seizure in 24 hours)

By submitting this form to Northwest Veterinary Specialists (“NWVS”), I/we confirm that I/we have express consent from the individual(s) concerned to transfer the personal data set out in this form to NWVS

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What is your key question regarding this case?

Vet Professionals

Seizures Advice

Please complete the online advice form below.
If you have any further queries email: [email protected]

Owner details

Practice details:

Patient details

Investigations performed to date

About

Pet Owners

Veterinary Professionals

Contact

Vet Professionals

Seizures Advice

Please complete the online advice form below. If you have any further queries email: [email protected]

Owner details

Practice details:

Patient details

Investigations performed to date

About

Pet Owners

Veterinary Professionals

Contact

Please complete the online advice form below.
If you have any further queries email: [email protected]