TVSC – Patient Registration Form – Tarheel Veterinary Surgical Specialists

First name *

Last name *

Owner email address *

Your phone number *

Street address *

Street address line 2

City *

State *

Postal/zip code *

First name (secondary contact)

Last name (secondary contact)

Phone number (secondary contact)

Pet name *

Pet date of birth *

Pet sex/sterilization *

Pet species *

Pet breed *

Pet color *

Pet picture *
(Max file size 10MB in jpg, gif, or png format)

How did you hear about us? *

Referring veterinary practice *

Referring veterinarian *

Referring practice phone number *

Who is your pet’s primary care veterinarian? *

Pet insurance provider (leave blank if none)

Is your pet currently seeing any other Veterinary Practices? If yes, please list them.

Presenting concern *

Which limb *

Date of Onset (Estimated) *

Progression *

Has your pet been evaluated for this concern? *

Has any imaging been performed? *
X-RayCTMRIUltrasoundNoneOther

Date of imaging

What was the diagnosis and recommended treatment plan? *

Does your pet have any other medical concerns or conditions?

Is your pet currently on any medications aside from routine flea/tick/heartworm preventatives? *
YesNo

Has your pet had a previous orthopedic surgery? *
YesNo

Are you a current patient of Tarheel Veterinary Surgery Center? *
YesNo

If applicable, are you interested in surgical intervention?