(Sid) Revised Client Surgery Request Form

Client Surgery Request Form

This form is intended for use by pet parents. If you are a referring veterinarian please fill out the 'Referring Veterinarian Surgery Request Form' found in the main menu.
Please note that we do not offer routine spay and neuter services or TPLO (cruciate, ACL) surgery.

For a low-cost TPLO option, please visit Treat Veterinary Surgery Service's website.
Primary Contact Name (Pet Parent)

First NameLast Name
Primary Contact DOB

MonthDayYear
Date
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email Address
example@example.com
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Referring Veterinary Facility
Name of clinic
Pet Information
Pet's Name
Pet's Age
Please specify years or months
Sex
Is your pet spayed or neutered?
Pet's Species
Pet's Breed
Examples: German Shepherd, Chihuahua Mix, Pit Bull
Have you applied for financial assistance at the referring veterinary facility (for example, Care Credit or Scratchpay)?
This information does not affect approval or denial of this surgery request.
Surgery Information
Type of Surgery Requested
If you have selected 'Other' please refer to our website to confirm we offer this surgery and clarify the type of surgery requested in the large text box below titled 'Additional Surgery Information'
Urgency of Surgery Request
If your veterinarian has not indicated the urgency of you pet's surgery please select 'Unsure'.
Additional Surgery Information - REQUIRED if Type of Surgery Requested is "Other"
Is your pet on any medications currently?
If you have selected 'Yes', please list the medication(s) name, dose, and frequency in the box to the right.
List of Current Medications (If Applicable)
See below for instructions regarding listing medications with the appropriate information ('Example List of Current Medications', 'Example Medication')
Example List of Current Medications
Medication Name
Medication X mg or mg/mL
Amount Administered   X (tablets, capsules, mLs)
Frequency of Administration   Every X hours or X times daily
Example Medication
Medication Gabapentin
Medication 300mg
Amount Administered   1 capsule
Frequency of Administration   Every 12 hours (twice daily)
Has your pet been diagnosed with any other conditions or previously had surgery?
If you selected 'Yes', please include a list of previous surgeries and diagnoses in the text box to the right.
List of diagnoses and previous surgeries
Please include an approximate date of diagnosis/ surgery, Example: Diabetes, August 2019
We are unable to reply to requests for surgery or estimates of cost without all relevant patient records. Please upload all relevant records here, or ask your veterinarian to email them to squad@maverickveterinarysurgery.com:

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Messaging frequency may vary. Message and data rates may apply.You can opt out at any time by texting STOP. For assistance, text HELP or visit www.maverickveterinarysurgery.com. Visit https://www.maverickveterinarysurgery.com/privacy-policy-sms-terms for our Privacy Policy and Terms of Service. By providing your mobile number, you consent to receive SMS messages for medical communication and scheduling related to your pet. SMS consent is not shared or sold to third parties.
Conversations with Maverick Veterinary Surgery Service staff are recorded. Please authorize recording by selecting YES, below. If you choose NO, we will communicate with you via text and email only.
Signature

By signing above, I certify that the information provided is true and correct to the best of my knowledge
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Client Surgery Request Form

Please note that we do not offer routine spay and neuter services or TPLO (cruciate, ACL) surgery.

Pet Information

Surgery Information