Pre-Consult Form: Surgery – Soft Tissue Client InformationDate(Required) Month Day Year Client Name(Required) First Last Pet's Name(Required) Species(Required) Dog Cat Email(Required) General Information/HistoryWhen 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.DrugStrength (mg per capsule/tablet)Dose ( how many capsules/tablets given per dose)Frequency (how often)First StartedLast dose givenSide effects: Add RemovePlease list all veterinary facilities that have treated or examined your pet in the last two years.(Required)Soft Tissue IntakePlease 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