2965 Edinger Avenue Tustin, CA 92780

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Forms & Feedback

Find forms and links below for your convenience.

You may complete and submit our New Client/Patient Information & History Form (below) prior to your visit.
Go to our Testimonials page by clicking this link and send us your story: Feedback/Testimonials

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

Date of your upcoming appointment*

Client Information

How did you hear about Veterinary Surgical Specialists?*
Referred by my veterinarian or another specialistReferred by a friend/ breederInternet or Social MediaYou Treated Another Pet Of MineOther

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*

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

Have you taken your pet to any other veterinary offices for this issue?*
YesNo

If yes, please list each veterinary office your pet has visited for this condition.

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?

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

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

Anesthesia

When did your pet last have food or water?*

Has your pet undergone anesthesia 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.

Veterinary Surgical Specialists

2965 Edinger Avenue
Tustin, CA 92780
P: 949.936.0055
F: 949.936.0062
E: info@vssoc.com
Located inside the AVSG building

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