Patient History 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* ---Cell PhoneHome PhoneWork PhoneFax Additional Phone Additional Phone Type ---Cell PhoneHome PhoneWork PhoneFax Additional Phone 2 Additional Phone 2 Type ---Cell PhoneHome PhoneWork PhoneFax Additional Phone 3 Additional Phone 3 Type ---Cell PhoneHome PhoneWork PhoneFax 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 and duration of current problem?* 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 The cost for the initial consultation is $125. I understand that the minimum cost of this appointment is $125 and I agree to pay in full for this and any other services I have agreed to at the time of consultation. PLEASE INITIAL IN THE BOX BELOW TO ACCEPT THESE TERMS* All medical fees must be paid in full at the time of service. You will be given an estimate for the cost of any services based on the doctor's initial examination of your pet.
