Section 1 of 3
Botika't Reseta: Contact form
Terms and Agreement
Section 2 of 3
Patient Profile
Patient's Specie
Patient's Specie
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Dog
Cat
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Terms and Agreement:
Veterinary Botika at Konsulta with Doc Loy is a virtual clinic, thus we provide a Veterinary clinic service with the best of our ability, but with known limitations.
We urge you to make sure that the condition must not be with Emergency cases as we were not held liable for any damage incur with it.
Terms and Agreement:
Veterinary Botika at Konsulta with Doc Loy is a virtual clinic, thus we provide a Veterinary clinic service with the best of our ability, but with known limitations.
We urge you to make sure that the condition must not be with Emergency cases as we were not held liable for any damage incur with it.
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Patient's Name:
Ex. Panda Gomez
Patient's Name:
Ex. Panda Gomez
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Patient's Age:
Patient's Age:
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Gender
Gender
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Male (intact)
Male (Neutered/ Castrated)
Female (intact)
Female (Spayed)
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Breed
Breed
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Body Weight in Kgs.
(Please provide exact body weight using weighing scale)
Body Weight in Kgs.
(Please provide exact body weight using weighing scale)
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Needs Emergency Services?
Needs Emergency Services?
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Yes
No
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Reason for online consult
Reason for online consult
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Skin Problem
Ear Problem
Eye Problem
Limping
Other:
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Patient Condition Overview:
Patient Condition Overview:
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Short Description of the problem to be consulted:
(Ex. Itchy skin, Foul smell on the ears, cloudy eyes)
Short Description of the problem to be consulted:
(Ex. Itchy skin, Foul smell on the ears, cloudy eyes)
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Duration of the Problem:
(Ex. 1day, 1week, 1month ago, recurring)
Duration of the Problem:
(Ex. 1day, 1week, 1month ago, recurring)
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Medication Given; (if any)
Medication Given; (if any)
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Section 3 of 3
Client Information
Owner's Name
Owner's Name
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Address
Address
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Contact number
Contact number
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Schedules available:
Sunday 12:00-3pm
Monday 6pm-10 pm
We will be calling to confirm your booking. Thank you
Schedules available:
Sunday 12:00-3pm
Monday 6pm-10 pm
We will be calling to confirm your booking. Thank you
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