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| 780-570-9999
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Menu
Home
About
Meet Our Team
Careers
Contact
Departments
Cardiology
Dentistry & Oral Surgery
Diagnostic Imaging
Emergency and Critical Care
Internal Medicine
Neurology
Ophthalmology
Surgery
Pet Owners
What To Expect
Referral Process
Pet Admission Forms
FAQ
Orthopedic Foundation for Animals (OFA)
Veterinarians
Submit a Referral
Continued Education
Testimonials
EMERGENCY
| 780-570-9999
Submit a Referral
Surgery Questionnaire
Surgery Questionnaire
Problem Area
Date
*
MM slash DD slash YYYY
Client Information
Owner's Name
*
First Name
Last Name
Primary Phone Number
*
Email Address
*
Do you have medical insurance for your pet?
*
Yes
No
What company is it with?
*
Do you consent to having your pet included in educational and promotional material used on websites, social media and in professional presentations? This could include photographs, diagnostic images, patient medical information, and pet's first name.
*
Yes
No
Patient Information
Pet's Name
*
First
Date of Birth
*
MM slash DD slash YYYY
Breed
Gender
*
Female
Female Spayed
Male
Male Neutered
Is your dog a working-dog?
*
Yes
No
What type of work?
*
Please explain
Surgery Questionnaire
In just a few words please indicate the problem you are coming in for
*
Symptoms
What signs did you first notice?
*
How long have the signs been going on for?
*
Please enter a number greater than or equal to
0
.
Duration Unit
Days
Weeks
Months
Has the problem progressed/not changed/improved?
*
Progressed (worsened)
Not changed
Improved
Medications
What medications have been given for this problem?
Was there improvement with the medications?
*
No
Slight
Moderate
Complete
What medications is your pet currently taking?
include any medications including those for other conditions, along with supplements or over the counter medication
Quality of Life
Does your pet pay attention to the problem?
*
eg. Turning suddenly, scratching, chewing, licking
Yes
No
Are any of the following affected by this condition?
*
Indicate 0 if normal/not affected and 5 if profoundly affected/unable to perform.
0
1
2
3
4
5
N/A
The ability to rest comfortably
Walking
Trotting/running
Jumping up
Jumping down
Appetite
Ability to do normal daily activities in comfort
Overall energy levels
Interest in daily activities and interaction with you
Interaction with other pets
When are signs most pronounced?
*
First thing in the morning or when getting up from laying down
At the start of exercise but then “warms out of it”
At some point during or near the end of exercise
Always
Other health concerns or comments
Are there other health or behavioural concerns that impacts your pet?
*
Yes
No
other health or behavioural concerns
Please list
Are there any other concerns we should be aware of?
*
Yes
No
Other concerns
Please list
