CASE SUBMISSION INFORMATION Case Submission Type Your Name & Academic Degrees Contact Supervising Type Your Supervising Veterinarian’s Name & Academic Veterinarian Degrees Practice Name & Type Your Practice’s Name Phone Practice City & Type Your Practice’s City & State State Supporting Are you providing photos with this case? Yes or No Photos? PATIENT INFORMATION Patient Name Type Name Patient Age & Gender Type Age & Gender Species and Breed Type Species & Breed Patient’s Symptoms Are you providing videos with this case? Yes or No Include location and associated symptoms Include current and past diagnoses, Medical History medications, etc. Initial Assessments Type results of any initial tests Initial Diagnosis Type Initial diagnosis Supporting Video? TREATMENT INFORMATION Laser Make & Model Type the laser make & model used for treatments Frequency of Treatment Enter how often treatments were applied and time between treatments Protocol Used Enter Built-In protocol used and/or patient characteristics (skin color, body type) Mode Enter CW or frequency (Hz) used to administer treatment Power Enter power setting in Watts (W) Treatment Time Click here to enter duration(s) of each laser treatment session Total Energy Delivered (= Power x Enter total energy (Joules) delivered during treatment Time) Treated Enter body part locations of treatment Approximate Size of Area Enter the size of the area treated in cm2 Treated (in cm2) Other Treatment Details Enter details about the treatment head used and the distance held from the skin Any Other Treatments Used Enter any other treatment techniques, approaches or protocols used Assessment Used Enter assessments, functional and quantitative measures are best
CASE SUBMISSION INFORMATION Case Submission Contact Type Your Name & Academic Degrees Supervising Veterinarian Type Your Supervising Veterinarian’s Name & Academic Degrees Practice Name & Phone Type Your Practice’s Name Practice City & State Type Your Practice’s City & State Supporting Photos? Are you providing photos with this case? Yes or No Supporting Video? Are you providing videos with this case? Yes or No PATIENT INFORMATION Patient Name Type Name Patient Age & Gender Type Age & Gender Species and Breed Type Species & Breed Patient’s Symptoms Include location and associated symptoms Medical History Include current and past diagnoses, medications, etc. Initial Assessments Type results of any initial tests Initial Diagnosis Type Initial diagnosis TREATMENT INFORMATION Laser Make & Model Type the laser make & model used for treatments Frequency of Treatment Enter how often treatments were applied and time between treatments Protocol Used Enter Built-In protocol used and/or patient characteristics (skin color, body type) Mode Enter CW or frequency (Hz) used to administer treatment Power Enter power setting in Watts (W) Treatment Time Click here to enter duration(s) of each laser treatment session Total Energy Delivered (= Power x Time) Enter total energy (Joules) delivered during treatment Treated Enter body part locations of treatment Approximate Size of Area Treated (in cm2) Enter the size of the area treated in cm2 Other Treatment Details Enter details about the treatment head used and the distance held from the skin Any Other Treatments Used Enter any other treatment techniques, approaches or protocols used Assessment Used Enter assessments, functional and quantitative measures are best