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152 Sparrowbush Road, Latham, New York 12110

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518.783.3199

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Home » Pre-Consult Form: Surgery – Soft Tissue

Pre-Consult Form: Surgery – Soft Tissue

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

No

If yes, at what age?

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

Yes

No

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

Yes

No

Does your pet travel?(Required)

Yes

No

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

Yes

No

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

No

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

No

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

Check all that apply:

Coughing

Sneezing

Vomiting

Diarrhea

None

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

Yes

No

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)

Soft Tissue Intake

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

What was the date of onset?(Required)

To the best of your knowledge

Is this an acute or chronic issue?(Required)

Acute (sudden onset)

Chronic (developed over time)

Have the symptoms become worse over time?

Yes

No

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Hours of Operation

Specialty Services: Monday – Friday 8am-6pm
*Subject to change during Holidays

Emergency Service: 24 hours a day / 7 days a week

Upstate Veterinary Specialties, PLLC

152 Sparrowbush Road, Latham, New York 12110
Phone: 518.783.3198 Fax: 518.783.3199

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