Case Submission Form – Texas Specialty Veterinary Services, PLLC

This form was submitted by: *

Referring Clinic: *

Email addresses you would like the TSVS Dr. reply sent to: *

Please separate email addresses with a semicolon and ensure the spelling is correct.

Referring DVM *

Patient Name *

First

Last

Weight (in lbs.) *

Breed *

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? TSVS 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

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 60 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

I understand the clinic will incur a cancellation fee of $500 if the procedure is cancelled within 24 hours of the scheduled surgery date. Therefore we recommend collecting an adequate deposit. *

Yes

Liability

We, the referring veterinary practice, understand we are responsible for the anesthetic decision making as well as administration and monitoring of anesthesia throughout the surgical procedure and recovery. *

Yes
No

We, the referring veterinary practice, understand that Texas Specialty Veterinary Services are not liable for any anesthetic related complications for this patient's procedure. *

Yes
No

We, the referring veterinary practice, have reviewed the above detailed liabilities with the patient's owner. *

Yes
No

We, the referring veterinary practice, have reviewed the surgical procedure including risks and complications with the patient's owner. *

Yes
No

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Liability

We provide safe and reliable surgical care for the pet’s of Texas.

San Antonio, TX