Client Information

Please complete the information below. For any questions please call 949.936.0055.

Date of your upcoming appointment *

How did you hear about us? *

Owner's Name *

First Name

Last Name

Spouse/Partner's Name

First Name

Last Name

Best Contact Phone Number *

Best Contact Number Type *

Home Address *

Street Address

Street Address Line 2

City

State

Zip

Cell Phone Number

Home Phone Number

Alternative Phone Number

Email *

Preferred Method of Communication *

Employment Information

Occupation

Employer

Work Address

Street Address

Street Address Line 2

City

State

Zip

Driver's Information

Driver's License Number

Driver's License Expiration Date

Driver's License State

Driver's Date of Birth *

Pet Information

Pet's Name *

First Name

Last Name

Weight *

Breed *

Sex *

MaleFemale

Age *

Neutered/Spayed? *

YesNo

Color *

Medical Care

Primary Care Veterinarian *

First Name

Last Name

Hospital Name *

Hospital Phone

Hospital Address

Street Address

Street Address Line 2

City

State

Zip

Have you taken your pet to any other veterinary offices for this issue? *

YesNo

Reason for consultation today and duration of current problem? *

Has your pet had labwork done? *

YesNo

Date of most recent labwork

What is the name of the veterinary office that did these labs?

Has your pet had x-rays done for this issue? *

YesNo

Date of most recent x-rays

What is the name of the veterinary office that did these x-rays?

Medical History

Please send any records or x-rays you may have to our email address: info@vssoc.com

Please describe your pet's medical and surgical history *

How would you characterize your pet's temperament? *

Does your pet have a history of seizures? *

YesNo

Please describe your pet's current and/or past medication and vaccination history with dates *

Has your pet had any drug reactions/allergies? *

YesNo

Does your pet show any of the following signs? *

Orthopedic Problems

Lameness has come on...

Lameness after exercise is...

Lameness after heavy exercise is...

Lameness after resting is...

Anesthesia

When did your pet last have food or water? *

Has your pet undergone anesthesia before? *

YesNo

Is there any other pertinent/additional information or problems that you feel we should know about?

Signatures

Please read and agree to the terms, then sign and date below.

I am of legal age. I am the owner or authorized agent of the pet(s) presented to Veterinary Surgical Specialists. I understand that an initial examination will be performed, and a verbal or written estimate will be provided to me before any other services are rendered. I assume financial responsibility for all professional fees and agree to pay at the time services are rendered. If for any reason payment is not made, I agree to interest charged per annum, necessary attorney’s fee, court costs, late fees, and any other recovery fees.

I agree *

I agree

I understand that Veterinary Surgical Specialists consists of leaders and teachers in veterinary medicine, thus case information and/or photos may be used in teaching, documentation, continuing education, their website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; patient confidentiality will be maintained unless otherwise authorized.

I agree *

I agree

The cost for the initial consultation is $266.21. I understand that the minimum cost of this appointment is $266.21 and I agree to pay in full for this and any other services that I have agreed to at the time of the consultation.

I agree *

I agree

Owner/Authorized Agent eSignature *

Date *

Client Registration

Veterinary Surgical Specialists of Orange County

Client Information

Employment Information

Driver's Information

Pet Information

Medical Care

Medical History

Orthopedic Problems

Anesthesia

Signatures