Appointment Request Form Sinew Veterinary | Small Animals Sports Medicine & Orthopedic Medicine
Please complete this form to request an appointment for your dog. An initial consultation includes a comprehensive, non-sedated orthopedic and sports medicine evaluation. Additional diagnostics or procedures may be recommended and coordinated with your dog's veterinary clinic or with a participating veterinary clinic. Submitting this form does not confirm an appointment. After reviewing your request, Sinew Veterinary will contact you with appropriate next steps and scheduling options. Instructions for securely submitting medical records and diagnostic images will also be provided. This form is not monitored for emergencies. * indicates required fields
Appointment and Primary Owner Contact
Legal Owner's Name
*
First Name
Last Name
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
City
*
State
*
ZIP Code
*
Preferred Contact Method and Additional Contact
Best way to reach you with questions about this form
*
Cell phone call
Email
Text message
Additional authorized contact?
Yes
No
Additional Contact Name
First Name
Last Name
Additional Contact - Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Contact - Email
example@example.com
Relationship to Dog
Dog Information
Dog's Name
*
Do you know your dog's date of birth?
*
Yes
No
Dog's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If the exact date is unknown, enter the approximate age
Breed
*
Weight
*
Unit
*
lb.
kg
Sex / reproductive status
*
Male - intact
Male- neutered
Female - intact
Female - spayed
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Primary Veterinarian and Additional Clinic Details
Primary Veterinary Clinic
*
Primary Veterinarian Name
First Name
Last Name
Primary Clinic Location (City and State)
*
Primary Clinic Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Clinic Email
example@example.com
Is another veterinary clinic or specialist involved in your dog's current problem?
Yes
No
Additional veterinary clinics or specialists involved in your dog's care
Rows
Clinic name
Veterinarian
City
Phone
Email
Additional clinic
Additional clinic
Tell Us About Your Dog's Problem
Describe your dog's problem. Please include when you first noticed the problem, how severe it seems, whether it has changed over time, any treatments that have been tried, and whether they helped.
*
Has your dog been evaluated for this problem by another veterinarian?
*
Yes
No
What were you told about the problem? (Diagnosis, suspected diagnosis, recommendations, or other relevant information).
Has your dog had blood work within the last 12 months?
*
Yes
No
Not sure
Does your dog have any other medical issues unrelated to the reason for this visit?
*
Yes
No
Not sure
Please describe
Please describe your goals for your dog.
Daily and recreational activity goals - check all that apply
Comfortable daily activity / play
Walks up to 1-3 miles
Longer walks (> 3 miles)
Hiking
Other (please describe)
Return to working (Check all that apply)
Herding and stock work
Hunting
Police/Military work
SAR
Other (please describe)
Return to sports and performance (Check all that apply)
Agility
Dock diving
Flyball
Nose work
Obedience/rally
Schutzhund, AS, IGP, Ring Sports (Belgian, French, Mondioring), PSA, KNPV
Other (please describe)
Return to service or therapy work
Yes
No
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Veterinary Visit Information
How would you describe your dog's behavior during veterinary visits? (Choose the answer that fits best)
*
Comfortable with unfamiliar people and most veterinary handling
Friendly with people but not necessarily comfortable around other animals
Nervous or fearful around unfamiliar people or veterinary handling
May growl, snap, or become defensive when frightened or painful
Other (please describe)
Does your dog usually receive medication before veterinary visits to reduce fear, anxiety, or stress?
*
Yes
Sometimes
No
Not sure
Medication(s), dose, and when given, if known
Has your dog ever required a muzzle or other additional safety restraint during veterinary handling?
*
Yes
No
Please describe
Additional Medical Information
Does your dog have any known allergies or reactions to food, medications, sedation, anesthesia, or anything else?
*
Yes
No
Not sure
Please describe
Is your dog currently taking any medications?
*
Yes
No
Medication(s), dose, and when given, if known
Rows
Name
Dose (e.g., 50mg/tab)
Frequency (times/day)
Drug # 1
Drug # 2
Drug # 3
Drug # 4
Is your dog currently receiving any supplements? (for example, fish oil)
*
Yes
No
Please list of the supplement names, and daily dose (for example, Welactin 8 ml/day)
What diet is your dog currently receiving? Please include the main food or diet. The brand and approximate amount are helpful, if known.
*
Is there anything else we should know about your dog prior to their visit? If yes, please explain:
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Appointment Information
What type of appointment are you requesting?
*
Please Select
Initial consultation / new problem
Recheck/follow up
Diagnostic or procedure visit already discussed with Sinew
Not sure
If appropriate for this visit, which setting would you prefer?
Please Select
Veterinary clinic
Home visit
No preference
Home visits may be available for selected non-sedated consultations and exam-only rechecks within Sinew's service area. Visits requiring sedation, musculoskeletal ultrasound, injections, or other procedures requiring clinical support are performed at a participating veterinary clinic.
Street address
Scheduling Preferences
Submitting this form does not reserve a time. After Sinew reviews the request, you will be contacted with appropriate scheduling options based on visit type, location, and availability.
Which weekdays generally work for you? Check all that apply.
Monday
Tuesday
Wednesday
Thursday
Flexible
Preferred time of day:
Morning
Midday
Afternoon
Flexible
How soon would you like to be seen?
Earliest suitable appointment
Within 1-2 weeks
Within 2-4 weeks
Flexible / no specific urgency
Are there any dates or times you are unavailable during the next 2–3 weeks?
Medical Records & Diagnostic Images
You do not need to submit medical records or diagnostic images in order to complete this appointment request. After your request is received, Sinew Veterinary will provide instructions for securely sending relevant medical records and diagnostic images. Your primary veterinarian or referring clinic may also submit records directly.
Authorizations, Acknowledgments, and Electronic Signature
Authorization to obtain and review veterinary medical records
*
I authorize Sinew to communicate with the veterinary clinic(s) and veterinarian(s) listed on this form and to request, receive, and exchange medical information relevant to my dog's evaluation and care.
For home-visit requests only:
If I request a home visit, I understand that home-visit availability is subject to Sinew confirming that the visit is clinically appropriate and can be performed safely and efficiently at my location; Sinew may recommend a clinic-based visit instead.
Contact authorization
*
I authorize Sinew Veterinary to contact me using the information provided above for scheduling, appointment reminders, records requests, and care-related communication.
Appointment Request Acknowledgment
*
I understand that submitting this form does not confirm an appointment. Sinew Veterinary will review my request and contact me with appropriate next steps or scheduling options.
Submitted by
Printed Name
*
First Name
Last Name
Relationship to Dog
*
Owner
Authorized Agent
Submit
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