Forms & Feedback

New Client/Patient Information Please complete the information below. For any questions please call 949.936.0055.

How did you hear about Veterinary Surgical Specialists?*

Owner's Name*

Spouse/Partner

Home Address*

City*

State*

Zip/Postal Code*

Best Contact #*

Best Contact # Type*

Additional Phone

Additional Phone Type

Additional Phone 2

Additional Phone 2 Type

Additional Phone 3

Additional Phone 3 Type

Email*

Occupation

Employer

Work Address 1

Work Address 2

City

Work State

Work Zip

Driver's Lic.#

State

Exp Date

DOB*

Pet's Name*

Breed*

Age*

Color*

Weight*

Sex*
MaleFemale

Neutered/Spayed*
YesNo

Primary Care Veterinarian*

Hospital Name*

Address

Phone

State

Zip Code

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?

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?

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.

New Client/Patient Information Please complete the information below. For any questions please call 949.936.0055.

Client Information

Employment

Driver's Information

Pet Information

Medical Care

History

Medications Please provide a copy of your veterinarian's medical record pertinent to your pet's problem:

Symptoms

Orthopedic Problems (if not applicable, select n/a)

Anethesia

Veterinary Surgical Specialists