This form was submitted by: *

Owner Name *

First

Last

Owner Phone Number *

Owner Email *

Referring Clinic: *

Email address you would like the HCVSS Dr. reply sent to: *

Additional email address you would like the HCVSS Dr. reply sent to:

Referring DVM *

Patient Name *

First

Last

Patient's Age *

Weight (in lbs.) *

Breed *

Sex *

Body Condition Score (BCS) *

Presenting Complaint: *

History: *

Exam Findings: *

Which limb(s) is affected? *

Please type N/A if this is not applicable to this patient.

Was drawer appreciated on exam, if stifle is of concern? *

Yes
No
Unsure
N/A

Are you submitting a case for a MPL or LPL? *

MPL
LPL
N/A

What grade is the patella luxation? *

/4
N/A
Notes:

Notes:

Are there any open sores or wounds associated with the affected site if fracture is the primary concern? *

Yes
No
N/A

Have preoperative radiographs been taken/submitted? HCVSS requires preoperative radiographs with calibrated digital markers present prior to the scheduled surgery date. *

Yes
No
N/A

If you are submitting post op radiographs (generally weeks 2-10), How is the patient doing clinically on the repaired limb? *

If this is not applicable for this case submission, please type N/A.

Was the pet sedated during the radiographs? *

Yes
No

Is there a physical marker in your radiographs? *

Yes
No

Is this a Dr. or employee pet? *

Yes
No

Does this patient have severe anxiety or aggression during his/her veterinary visits? If so, please explain below.

Additional Comments:

Please attach Radiogaphs here. These must be in JPEG format.

Click or drag files to this area to upload. You can upload up to 10 files.

Notes

Has the patient had a CBC & Chemistry done within the last 30 days? *

Yes
No
N/A

Notes

Attach Bloodwork here

Click or drag files to this area to upload. You can upload up to 10 files.

PDF Format

If the patient has any additional documents that need to be reviewed by our Dr.'s, such as an ultrasound report or culture results, please attach.

Click or drag files to this area to upload. You can upload up to 10 files.

PDF Format

HCVSS requires patient to be updated/current with the Rabies vaccine. Please upload vaccine history here.

Click or drag a file to this area to upload.

A cancellation fee of $500 will be charged if the procedure is cancelled or rescheduled within 24 hours (not to include Saturday or Sunday as TSVS is closed on weekends) of the scheduled surgery date. *

Multiple Choice *

I have read and acknowledge the cancellation fee.

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