Surgery & Orthopedics Patient History Form | Austin Veterinary Emergency Center

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7300 Ranch Rd 2222, Austin, TX 78730
Email: [email protected]
Emergency Hours: 24/7/365
Specialty Hours*: M – Sat: 8am – 6pm
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Surgery & Orthopedics Patient History FormAustin Veterinary Team2020-12-14T12:50:13-06:00

Surgery & Orthopedics Patient History

Name*
First Last
Patient Name*
Date
MM slash DD slash YYYY
Why were you referred to our facility?
What symptoms have you observed at home?*
If your patient has a limp, abnormal gait, and/or behavior, do you have capabilities to provide an at home video?
- Yes
- No
If yes, are you able to e-mail the video to us [email protected]?
- Yes
- No
When did the symptoms start?*
Are the symptoms:
- Progressing
- Staying the same
- Improving
Has your pet had or currently have any other medical conditions including hospitalizations and surgeries?"
What medications (if any) is your pet currently taking, including any supplements, over the counter medications, and preventatives?
If medications are being used to treat the condition for which we are evalutating your pet, have they been associated with any improvement in the condition?
Will you or your referring veterinarian be providing medical records?
- Self
- Referring Veterinarian
Have any radiographs (x-rays) been taken for this issue?
- Yes
- No
If yes, will you be bringing the radiographs with you or will they be provided by your referring veterinarian?
- Self
- Referring Veterinarian
Was an ultrasound performed for this issue?
- Yes
- No
If Yes, will you be bringing the ultrasound report with your or will it be provided by your referring veterinarian?
- Self
- Referring Veterinarian
Have any laboratory tests been performed, including bloodwork, cultures, cytology or histopathology?
- Yes
- No
If yes, please indicate which tests were performed
- bloodwork
- cultures
- cytology
- histopathology
What kind of food do you feed your pet?*
How much per day?*
Do you have other pets?
- Yes
- No
Do you have Pet Insurance?
- Yes
- No
If yes, which provider and what is your policy number?
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7300 Ranch Rd 2222, Austin, TX 78730

Tel: 512-343-2837 Fax: 512-343-2844
Emergency Hours: 24/7/365
Specialty Hours: M – Sat: 8am – 6pm
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