Surgery Intake Form | Veterinary Emergency and Specialty Centers of New Mexico

Owner Name:*

First Last

Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone*

Cell Phone*

Work Phone*

Referring Veterinarian*

Clinic Name*

Clinic Phone Number*

Pet's Name*

Breed*

Sex*

Male
Female

Neutered/Spayed*

Yes
No

Color*

DOB*

History

Please 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?*

Yes
No

If yes, at what time?

Generally what is your pet's activity level?*

Sedentary
Minimal Exercise
Moderate Exercise
Heavy Exercise

For 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?*

Improved
Worsened
Remained Static

If this is an orthopedic problem, is it worsened by exercise?*

Yes
No

Is 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?*

Yes
No

If 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)*

Yes
No