Surgery Intake FormOwner Name:* First Last Home Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Home Phone*Cell Phone*Work Phone*Referring Veterinarian*Clinic Name*Clinic Phone Number*Pet's Name*Breed*Sex*MaleFemaleNeutered/Spayed*YesNoColor*DOB* HistoryPlease place "N/A" if not applicable or does not apply.What do you typically feed your pet?*Volume*Frequency*Have you fed your pet today?*YesNoIf yes, at what time?Generally what is your pet's activity level?*SedentaryMinimal ExerciseModerate ExerciseHeavy ExerciseFor what problem are we seeing your pet today?*When did you first notice a problem?*What symptoms did you first notice?*Has the problem improved, worsened, or remained static since it's initial onset?*ImprovedWorsenedRemained StaticIf this is an orthopedic problem, is it worsened by exercise?*YesNoIs the problem more evident at a certain time of day?*Please list any medications you are currently giving your pet to treat this problem. If possible, include dose, frequency, duration, and whether any response is noted.* Please list any medications you have given your pet in the past to treat this problem. If possible include dose, frequency, duration, and whether any response was noted.* Did your veterinarian perform any tests/diagnostic procedures?*YesNoIf so, what? Does your pet have any allergies to medications, history of seizures, or other pertinent medical information?* Would it be alright for us to add a picture of your pet on our website/ social media sites? (None of your personal information will be shared besides your pet's name)*YesNo