Companion Case Study Form

Case Submission Information

Thank you for providing a case study report for Companion Animal Health! Please fill in the information below as completely as possible. Please also note that this report may be used for promotional purposes by and on behalf of Companion Animal Health, including publication as part of an educational series.

If you have any questions while filling out this form, please contact Ren Houyoux at 1 (302) 709-0408 Ext. 1507 or renaudh@companiontherapy.com.
Case Submission Contact Full Name *
Email Address of Contact *
Name of Supervising Veterinarian *
Practice Name *
Practice Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Patient Information
Patient Signalment *

Please include species, breed, age, and gender).
Patient History *

Include location and associated symptoms.
Medical Exam Findings *
Diagnostics Performed and Results *

Please attach any relevant radiographs, CT scans, MRI results, etc below.
File 1 Associated with Diagnostics. *

Please attach any supporting videos or images that show patient prior to beginning treatment.
File 2 Associated with Diagnostics.
File 3 Associated with Diagnostics.
Treatment Information
Treatments Performed *

Please list all treatments performed.
Frequency of Treatments *

Please provide treatment frequency and dosing information for each treatment provided.
Areas Treated *

Enter body part locations of treatment
Approximate Size of Treated Area (in cm2)

If treating with laser therapy, enter the size of the area treated in cm2. Reminder: 100 cm2 is approximately the size of a CD or the palm of your hand.
Other Treatment Details

Enter any other details about the treatment (not already included above) that you believe are relevant.
Any Other Treatments Previously Tried
Results
Discuss patient response to treatment. Explain any correlations or inconsistencies. Attach relevant images, tables or graphs below. *
File 1 Associated with Results *

Please attach any supporting videos or images that show patient improvement during and/or after treatment.
File 2 Associated with Results
File 3 Associated with Results
File 4 Associated with Results
File 5 Associated with Results
I hereby assert that I have obtained consent from the client involved in this case study to share the above case details (including any provided photos or videos) and obtained client consent for Companion Animal Health (a division of LiteCure, LLC) to use any and all related details of this case for various educational and promotional purposes. * By checking this box I acknowledge my agreement with the statement directly above

Companion Case Study Form

Companion Case Study Form

Case Submission Information

Patient Information

Treatment Information

Results