Internal Medicine Case Submission Form

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Internal Medicine Case Submission Form

Use this form to submit cases to the IDEXX Telemedicine. Our specialists are available Monday-Friday 7:30 a.m. to 11:00 p.m. ET, and Saturday 8:00 a.m. to 9:00 p.m.

If you have not registered for an account please do so. If you have any questions about the form or a case you've already submitted, call 1-800-726-1212, ext. 2270 or e-mail telemedinfo@idexx.com.

*indicates a required field

Customer Number


Clinic Information
Doctor's First Name*		Doctor's Last Name*
E-mail Address*		Title
Telephone*		Fax*
Hospital Name*		Address*
Address Line 2		City*
State/Province (U.S. and Canada)*		ZIP/Postal Code*

Patient Information
Patient*		Owner*
Breed*		Weight (lbs.)*
Species*		Gender*
Age* yrs. mos. wks.

Consult* First Repeat
First consult mm/dd/yyyy		Most recent mm/dd/yyyy

Type of Service*

Comprehensive Internal Medicine Telemedicine Evaluation (combination of clinical data, including images)
If you have an Abdominal Ultrasound or an Echo (clips or stills) please select a Comprehensive Evalutaion option and specify whether the images should be evaluated by an Internist, Radiologies or Cardiologist.

Routine: Please send me a report within 24 hours.
STAT: Please have a specialist call me within one hour. (addition charges will apply)

Medical History

When a more complete history is warranted, please complete and Fax the detailed medical history form to 1-888-357-0321. (419 KB)

Fax Sent*	Yes	No
Cough	Yes	No	Duration	Acute		Chronic

Chief Complaint:

Additional Notes:

If you have not already done so, please attach your image(s). The maximum, combined size of the files submitted must be less than 80 MB.

File 1:

If you have any problems with this form or questions about submitting images please call
1-800-726-1212 ext. 62270.