Second Consultation Request Form

INSTRUCTIONS: Please print out and complete the following form. Fax both the completed Second Consultation Request Form and the Recheck Behavior Fax Sheet and  to 1-508-839-8734. If you have questions, call 1-508-887-4640.

Date:
Fee per consult is $117
Method of Payment:
VISA  MasterCard  Discover  Personal Check*
Credit Card Number:
Expiration Date:  ____/____/____      Signature:
* Personal Check - Personal checks are accepted.
   Your check should be made payable to Trustees of Tufts and
   must be received before the consultation will be done.
Total # pages to be faxed (if faxed): 
Area Code and Fax Number:  (______) ______-____________
Area Code and Phone Number:  (______) ______-____________
Owner's Name: 
Pet's Name:
Clinic Case Number (if you have one): 

Thank you for using PetFax.

Back to PetFax