Patient History New Client/Patient Information Please complete the information below. For any questions please call 949.936.0055. Date* Client Information How did you hear about Veterinary Surgical Specialists?* Referred by my veterinarianReferred by a friendInternet researchSocial MediaOther Owner's Name* Spouse/Partner Home Address* City* State* Zip/Postal Code* Home Phone Work Phone Cell Phone* Fax Best Contact #* Email* Employment Occupation Employer Work Address 1 Work Address 2 City Work State Work Zip Driver's Information Driver's Lic.# State Exp Date DOB* Pet Information Pet's Name* Breed* Age* Color* Weight* Sex* MaleFemale Neutered/Spayed* YesNo Medical Care Primary Care Veterinarian* Hospital Name* Address Phone State Zip Code History Please describe your pet's medical and surgical history* Does your pet have a history of seizures?* YesNo How would you characterize your pet's temperament?* Medications Please provide a copy of your veterinarian's medical record pertinent to your pet's problem: Vaccination history with dates? Has your pet had any drug reactions/allergies?* YesNo If so, list description and dosage? Does your pet currently receive any medication?* YesNo If so, list description and dosage? Symptoms Does your pet show any of the following signs: (check all that apply)* Chronic coughing/sneezingRunny eyes/noseIncreased urinary frequencyChronic vomiting/diarrheaExercise intoleranceNone Date of most recent x-rays What is the name of the veterinary office that did these x-rays? Reason for consultation today* Date of most recent labwork What is the name of the veterinary office that did these labs? Orthopedic Problems (if not applicable, select n/a) Lameness has come on n/aSuddenlyGradually Lameness after resting is n/aBetterWorse Lameness after exercise is n/aBetterWorse Lameness after heavy exercise is n/aBetterWorse Anethesia When did your pet last have food or water?* Has your pet undergone anethesia before?* YesNo If so, were there any complications? Is there any other pertinent/additional information or problems that you feel we should know about?* YesNo If yes, please explain All medical fees must be paid in full at the time of service. You will be given an estimate for the cost of service based on the doctor's initial examination of your pet.