Pharmacology Consult Request Form

First Name

Last Name

Contact Email Address

Contact Phone Number

Phone

Drug(s)

Patient Signalment and Brief History

Please describe the patient (age, gender, breed, etc.) and provide a brief history.

Product Name and Source

Compounder Name and Product Description (if Applicable)

Product Name/Source

I don't know and need help identifying a commercial source for this drug.

The dose I am considering using is:

Dose

I need help selecting a dose.

The dosing regimen I am considering using is

Please describe the dosing regimen you are planning to use.

Is the patient taking any other drugs/nutritional supplements?

Yes

No

If you answered 'yes', please provide the name, dose, route, and dosing frequency.

If your question hasn't been addressed by one of the questions above, please provide your question below.