SPECIALITY SURGERIES

SPECIALITY SURGERIES
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Whats your pet's name*
My dog is:*
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?*
Was your pet diagnosed by a veterinarian*
A recent diagnosis by a veterinarian is required before completing this form. If your pet has not been examined by a veterinarian, please schedule an appointment at CHEW by calling 469-620-2828.
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

This will be required to book your surgery
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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?
If you have a picture of the injury, upload a picture. If your pet was diagnosed with a TPLO/MPL, upload a video of your pet walking, a controlled walking a straight line*

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How did you hear about us?*
What Hospital / Veterinarian referred you to CHEW?
If you have received a surgical estimate from another veterinarian, please upload it here. Because your pet has not been examined by our medical team yet, reviewing the prior estimate helps us understand what was recommended and ensures we include all necessary items when preparing your estimate.

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Need financial assistance?

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