SPECIALITY SURGERIES

SPECIALITY SURGERIES
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Whats your pet's name*
What species is your pet?*
What breed is your dog?*
Is your pet fixed (spayed/neutered)? *
How old is your pet?*
Approx weight of your pet?*
A RECENT (WITHIN 21 DAYS) DIAGNOSIS BY A VETERINARIAN IS NEEDED BEFORE FILLLING OUT THIS FORM. IF YOUR PET HAS NOT BEEN SEEN BY A VETERINARIAN, PLEASE MAKE AN APPOINTMENT AT CHEW, 469-620-2828.
Was your pet diagnosed by a veterinarian*
List any medication (name, dosage amount/instructions) your pet is one for this condition and how long s/he has been on it*
example: Rimadyl, 25mg, One pill twice a day, I have given in for 3 days
When did this injury/condition occur?*

MonthDayYear
Date
What surgery does your pet need?*
Please provide any additional information that will be helpful to CHEW about the needed surgery
Please upload all the records you have on the diagnosis - including xrays, bloodwork if applicable

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Click on any that are accurate about your pet*

My pet stopped eatingMy pet stopped uriniatingMy pet stopped defecatingMy pet is vomitingMy pet is having diarrheaMy pet is more lethargic than normalMy pet is not showing any symptomsOther
On a scale of 1-3, how much pain is your pet in?

1 - No pain2 - Moderate Pain3 - Severe Pain
How long has your pet stopped eating?
How long has your pet stopped defecating?
How long has your pet been vomiting?
How long has your pet had diarrhea?
How long has your pet been lethargic?
How long has your pet stopped urinating?
Upload pictures and/or videos - i.e A video of your pet walking up and down a hallway, picture of injury, etc. This is reviewed by the surgeon and very important for review before committing to a surgery.*

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How did you hear about us?*
What Hospital / Veterinarian referred you to CHEW?
Have you received an estimate of this surgery? Upload here, this will help us understand what treatment has been recommended for your pets surgery

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OTHER FINANCIAL RESOURCES:

CareCredit Find out if you're approved immediately
ScratchPay Find out if you're approved immediately
Waggle.org Find out if you're approved immediately
SPCA Email: helpmypet@spca.org
GoFundMe.com Very successful platform to raise money
CHEW Compassion Fund
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