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VSS Surgery Request Form

Thank you for choosing the surgery service at the Veterinary Surgery Specialists. Please fill out the following fields. Items with an asterisk (*) are required.
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Client Information

Client's Name *

Address *

Primary phone number *

Secondary phone number

Email *

Patient Information

Patient Name *

Approximate date of birth *

Approximate weight (in pounds) *

Species *

Sex *

Are they *

Breed *

Color *

Primary veterinarian's name *

Primary veterinarian's clinic name *

Primary veterinarian's phone number *

Reason for a Visit to Surgery

What is the primary medical concern to address at this appointment? *

Which limbs are affected (check all that apply) *

Has a veterinarian diagnosed this condition? *

Are you interested in pursuing surgery for your pet, if recommended by us? *

What treatments have been tried so far to address this condition (include medications, procedures, etc., as applicable)? *

When did this issue begin for your pet? *

Was there a known injury that caused this issue? *

What other health concerns does your pet have? *

Please attach your pet's medical records here if available *

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