Patient History Client & Patient Information Form Please complete the information below. For any questions please call 949.936.0055.You must complete all required fields in order to submit this form. New Client/Patient InformationDate of your upcoming appointment*(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client InformationHow did you hear about Veterinary Surgical Specialists?*(Required) Referred by my veterinarian or another specialist Referred by a friend/breeder Internet or social media You treated another pet of mine Other Owner's Name*(Required) Best Contact #*(Required) Spouse/Partner Best Contact # Type*(Required)Cell PhoneHome PhoneWork PhoneFaxHome Address*(Required) Additional Phone City*(Required) Additional Phone TypeCell PhoneHome PhoneWork PhoneFaxState*(Required) Additional Phone 2 Zip/Postal Code*(Required) Additional Phone 2 TypeCell PhoneHome PhoneWork PhoneFaxAdditional Phone 3 Additional Phone 3 TypeCell PhoneHome PhoneWork PhoneFaxHiddenEmail* Email(Required) EmploymentOccupation City Employer Work State Work Address 1 Work Zip Work Address 2 Driver's InformationDriver's Lic. # Exp DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920State D.O.B.*(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet InformationPet's Name*(Required) Weight*(Required) Breed*(Required) Sex*(Required) Male Female Age*(Required) Neutered/Spayed*(Required) Yes No Color*(Required) Medical CarePrimary Care Veterinarian*(Required) Phone Hospital Name*(Required) State Address Zip Code Have you taken your pet to any other veterinary offices for this issue?*(Required) Yes No Reason for consultation today and duration of current problem?*(Required)If yes, please list each veterinary office your pet has visited for this condition:Date of most recent labwork MM slash DD slash YYYY Date of most recent x-raysMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is the name of the veterinary office that did these labs? What is the name of the veterinary office that did these x-rays? HistoryPlease describe your pet's medical and surgical history:*(Required)How would you characterize your pet's temperament?*(Required)Does your pet have a history of seizures?*(Required) Yes No MedicationsPlease provide a copy of your veterinarian's medical record pertinent to your pet's problem. Upload files or input your pet's history manually below.Upload Files Drop files here or Select files Max. file size: 50 MB. Animal Medical History (vaccinations, medications, surgeries, etc.) With DatesHas your pet had any drug reactions/allergies?*(Required) Yes No Does your pet currently receive any medication?*(Required) Yes No If yes, please list description and dosage:If yes, please list description and dosage:SymptomsDoes your pet show any of the following signs? (check all that apply)*(Required) Chronic coughing/sneezing Increased urinary frequency Exercise intolerance Runny eyes/nose Chronic vomiting/diarrhea None Select AllOrthopedic Problems(if not applicable, select N/A)Lameness has come on... N/A Suddenly Gradually Lameness after exercise is... N/A Better Worse Lameness after resting is... N/A Better Worse Lameness after heavy exercise is... N/A Better Worse AnesthesiaWhen did your pet last have food or water?*(Required) Has your pet undergone anesthesia before?*(Required) Yes No Is there any other pertinent/additional information or problems that you feel we should know about?*(Required) Yes No If yes, were there any complications?If yes, please explain:I understand that Veterinary Surgical Specialists consists of leaders and teachers in veterinary medicine, thus case information and/or photos may be used in teaching, documentation, continuing education, their website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; patient confidentiality will be maintained.(Required) I authorize this release I do not authorize this release The cost for the initial consultation is $145. I understand that the minimum cost of this appointment is $145 and I agree to pay in full for this and any other services that I have agreed to at the time of the consultation.(Required) I understand and agree 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.CAPTCHA
