Home » Pre-Consult Form: Surgery – Orthopedic

Pre-Consult Form: Surgery – Orthopedic

Client Information

Date(Required)

Month

Day

Year

Client Name(Required)

First Last

Pet's Name(Required)

Species(Required)

Dog

Cat

Email(Required)

General Information/History

When did you acquire your pet?(Required)

Is your pet spayed or neutered?(Required)

Yes

If yes, at what age?

Is your pet up to date on vaccines?(Required)

Yes

Is your pet on regular flea and tick preventatives?(Required)

Yes

Does your pet travel?(Required)

Yes

Was your pet originally acquired from outside NY?(Required)

Yes

Is your cat:

Indoor only

Outdoor only

Both indoor and outdoor

What is your dog's life style?

Check all that apply

Mainly indoor

Mainly outdoor

Visits dog parks regularly

Visits groomers regularly

Goes to day care/boarding

Are there any other pets living in the household?(Required)

Yes

If yes, please list the species, age, and breed for other pet family members:

Please describe your pet's diet:(Required)

Please be specific and include the brand, type, and amount given daily. Please include treats.

Is your pet drinking and/or urinating more frequently?(Required)

Yes

Please tell us if your pet has been experiencing any of the following:(Required)

Check all that apply:

Coughing

Sneezing

Vomiting

Diarrhea

None of the above

Does your pet have any allergies to food or medications?(Required)

Yes

If yes, please describe:

Please list in detail any previous medical history including procedures, surgeries or diagnoses(Required)

Please list all current medications and supplements:

If none, leave blank. For multiple medications, use the plus sign.

Drug

Strength (mg per capsule/tablet)

Dose ( how many capsules/tablets given per dose)

Frequency (how often)

First Started

Last dose given

Side effects:

Please list all veterinary facilities that have treated or examined your pet in the last two years.(Required)

Orthopedic Intake

Please describe the reason for your visit including the chief medical complaint your pet is experiencing.(Required)

What was the date of onset of the injury?(Required)

To the best of your knowledge

Is this an acute or chronic issue?(Required)

Acute (sudden onset)

Chronic (developed over time)

Lameness Intake

Was the inciting cause of the lameness observed?(Required)

Yes

How long has the lameness been observed?(Required)

Please describe your dog's activity level before the onset of lameness:(Required)

Please describe your dog's activity level after the onset of lameness:(Required)

Has the lameness worsened, stayed the same, or improved?(Required)

Worsened

Stayed the same

Improved

Has the lameness improved with medications?(Required)

Yes

Not applicable

Does the lameness improve or worsen with exercise?(Required)

Improve

Worsen

Unsure

Have any diagnostics been performed?(Required)

Examples included bloodwork, radiographs, biopsy, etc.

Yes

If yes, please tell us what diagnostics:

What treatment(s) have been initiated and what was the response?(Required)

Treatments include rest and pharmacologic management

UVS News

Read our Blog featuring articles on latest medical topics and news.

Read Our Blog

Refer a Patient

Refer your patient to one of our Specialists. We provide optimal care to sick and injured animals.

Get Started

Our Specialists

Get to know our doctors’ training, certifications, and areas of specialization.

Meet Our Specialists