Please fill out the form below. If you have any radiographs and/or bloodwork, please email them to: DAHsurgeon@gmail.com

Client Name

First Name

Last Name

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Primary Phone Number

(###)

###

####

Client Secondary Phone Number

(###)

###

####

Client Email Address

Referring Veterinarian Name

Clinic Name

Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Clinic Phone

(###)

###

####

Clinic/Veterinarian Email

Pet Name

Species

Breed

Age

Sex

Color

Last Weight in Lbs

Body Condition Score: */9

FAS 0-5

Fear, Anxiety, and Stress Scale, is a tool used by our veterinarians to assess and gauge the level of emotional distress experienced by an animal, typically a dog, during certain situations or environments. (https://fearfreepets.com/fas-spectrum/)

Patient's Temperament:

Please select the following based on the patient's known history with your practice.

Vaccination History

Please indicate when the following vaccinations were given. If unknown, please leave blank.

Rabies

YYYY

1 year or 3 year

Rabies

Diagnosis

Indicate leg(s) of concern:

click all that apply

None

Left Rear

Right Rear

Left Front

Right Front

For Cranial Cruciate Ligament Ruptures (CCL) - If you are referring this patient for a Cranial Cruciate Ligament (CCL) Rupture at any point in the future if this patient begins having a suspected CCL rupture on the other leg, do you approve of them making an appointment directly with Dr. Montgomery rather than having to get a new referral?

Date radiographs were taken (if applicable):

YYYY

Were Radiographs Emailed to DAHsurgeon@gmail.com?

History/Previous Therapy

Known Allergies or Sensitivities

Current Medications

Date of referral:

YYYY