Medical History: Surgery Initial Consult
10436 173rd Street, Surrey, BC, V4N 5H3 Phone: 604-514-8383 | FAX: 604-427-2494 | bbvsh.com | info@bbvsh.com | This form can be found again at bbvsh.com/registration
Contact Information
Your name
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Your email
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Your pet's name
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Best phone number to reach you at today?
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(XXX) XXX-XXXX
Is there another phone number where you may be reached at?
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Yes
No, the above number is the best option to reach me
Alternate phone number
(XXX) XXX-XXXX
Your Concerns
What problem brings you here today (lameness / limping, mass, other)
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How long has the issue been going on?
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Was there any inciting event?
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Have there been changes to the problem, or anything that makes it worse?
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Have you had any evaluations and procedures done elsewhere? If yes, please elaborate.
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What are your goals today?
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Medications
Is your pet on any medication?
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Yes
No
If YES to the above, please list all your pets current medications
If YES to the above, for each medication, what dose (mg), and when are they given?
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Have the medications helped the issue at all?
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Did you give any medications just before TODAY’S visit? If yes, please specify which medication(s) and the dose.
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What Else Have You Noticed?
How is appetite, energy levels, urination, defecation and drinking habits?
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Any coughing, sneezing, vomiting, or diarrhea?
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Does your pet have any other ongoing, previous, or significant medical issues? Please list all as well as any previous significant diagnostics and surgeries performed.
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What diet is your pet on?
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Does your pet have any allergies? Please list them below:
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Have you travelled with your pet to the Interior or outside the province? If yes, when and where?
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Is your pet up to date on vaccines?
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OPTIONAL:
HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us for surgical treatment for your beloved pet:
e.g. vet recommends you for surgery, etc
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