Request for Surgery – VetSurgical

Tell us about you!

Name*

First Last

Have we seen you before?*

Yes
No

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone

Secondary Phone Number*

Email*

Tell us about your pet!

What is you pet’s name?*

Have we seen this pet before?*

Yes
No

What species is your pet?*

What is your pet’s breed?*

What is your pet’s gender?*

What is your pet’s age or birth date?*

What is your pet’s coat color?*

How much does your pet weigh?*

Does your pet have any allergies?

Yes
No

Describe the allergies your pet has.*

Please list any known allergies to medications, vaccines, as well as seasonal, flea or food allergies they may have.

Date of your pets most recent Rabies Vaccination.*

Rabies Vaccination must be up to date for surgery. We can update the vaccination if needed. Additional fees apply.

Tell us about your pet needs!

What is the requested date for surgery ?*

Requested Check In time?*

Morning Check-in day of surgery.
Afternoon Check-in the day before to Surgery

What procedure is needed ?

Please be as detailed as you can, including location on pet’s body.

Has your family veterinarian recommended this procedure?

When was your pet last seen by your family veterinarian?*

List all current medications your pet is currently taking.

Please include the medication name, dose, and how often your pet is currently taking the medication. This information should be listed on the prescription bottle.

Special notes, including current chronic health concerns.

Such as, heart, kidney or liver disorders, Cushing’s disease, thyroid disorders, diabetes, etc.

Have you already received a treatment plan with cost that you can not afford from your family veterinarian or referral center?*

Yes
No

How much was the estimated treatment plan your unable to afford?*

Have you Applied for Care Credit?*

Have an Care Credit account already.
Yes, and was declined.
Yes, and was approved.
No, I have not applied

Have you applied for Scratchpay?*

Yes, and been approved.
Yes, and was declined.
No, I have not applied.

Records Upload

Please attach medical records you may have about your pet’s current needs.

Drop files here or

Accepted file types: jpg, pdf, gif, , Max. file size: 100 MB.

Consent*

Our doctors are not Board Certified by American College of Veterinary Surgeons (ACVS). They are experienced and capable licensed general practitioners whose practice is limited to surgery or have a heavy surgery interest. If our doctors are unable to meet the surgical needs of you pet, they will be happy to refer you to an appropriate Specialist, and/or provide additional advice on your pet’s options. Our services are for those that trust our experience as they would a Board Certified Surgeon. Our training has been through experience with past cases and continuing education in surgery.

By clicking below you acknowledge you understand our doctors are not board certified specialist, nor do they claim to be, and you have been informed.

I understand the doctors at VetSurgical are not Board Certified by the ACVS.