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 * Feline Canine Breed * Age * Sex * Male Female Spayed Female Neutered Male Color * Last Weight in Lbs * Body Condition Score: */9 * 1 2 3 4 5 6 7 8 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/) 0 1 2 3 4 5 Patient's Temperament: * Please select the following based on the patient's known history with your practice. Affectionate/Average Sometimes fearful or aggressive, go slow. Consistently shows signs of fear or aggression, use caution! Requires special handling by owner or may require sedatives, use caution! Vaccination History Please indicate when the following vaccinations were given. If unknown, please leave blank. Rabies MM DD YYYY 1 year or 3 year Rabies One Three N/A 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? * I approve. I would rather see them first and then send a referral if needed. Not Applicable as they are not getting referred for a CCL Rupture Date radiographs were taken (if applicable): MM DD YYYY Were Radiographs Emailed to DAHsurgeon@gmail.com? * Emailed No radiographs taken History/Previous Therapy * Known Allergies or Sensitivities * Current Medications * Date of referral: * MM DD YYYY Thank you!Your message has been received and your client will be contacted to schedule an appointment.Please send your radiographs (if any) to DAHsurgeon@gmail.com