Orthopedic History Form

Consultation Intake & Orthopedic History Form

Client/Pet Owner Information

Name
Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal
Country
Preferred contact method(s)

Patient/Pet Information

Veterinary Care Team & Records Sources

Orthopedic Concern & History

What area(s) are affected? (Select all that apply)
What changes have you noticed? (Select all that apply)
Has your pet had any of the following performed for this issue? Select all that apply. Please ensure all records, reports, and diagnostic imaging are shared with The Sams Clinic.

Medical History & Medications

Does your pet have any current medical conditions or diagnoses?
Has your pet had any previous surgeries?
Does your pet have any known allergies or medication sensitivities?
Has your pet ever experienced a reaction or complication related to sedation or anesthesia?
Has your pet experienced vomiting, diarrhea, coughing, sneezing, fever, or another illness within the last 30 days?
Has your pet been diagnosed with any infectious disease or contagious condition within the last 30 days?
Does your pet have any behavioral concerns that may affect handling, examination, or hospitalization?

Acknowledgements & Consent

Acknowledgements

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Signature

Children playing outdoors with their dogs

Our Specialists

Dr. Andrew Sams, veterinary orthopedic surgeon

Andrew Sams, DVM, MS, DACVS

Founder & Medical Director
Orthopedic Surgery & Arthroscopy

Dr. Sherman Canapp, veterinary orthopedic surgeon and sports medicine specialist

Sherman Canapp, DVM, MS, CCRT, DACVS, DACVSMR

Orthopedic Surgery & Arthroscopy
Sports Medicine & Rehabilitation

Dr. Dana Whitlock, veterinary sports medicine and rehabilitation specialist

Dana Whitlock, DVM, MS, CCRP, CVA, DACVSMR

Sports Medicine & Rehabilitation

Patient Stories

Maicoh

Protection & French Ring

“Kraken is back doing all the things a healthy 5-year-old Border Collie should be doing. He loves sheep herding, agility, swimming, hiking, playing with his two Dutch Shepherd brothers and ruling our house. Maicoh has retired from French Ring and enjoys dock diving in his own dock-dog pool in our yard, hiking and trying to keep Kraken—and Maicoh’s son, Lycan—in line.’

Auggie

Agility

“Dr. Canapp and his team diagnosed and treated Auggie for an acute stifle injury in 2018 when he was 8 years old, helped him to fully recover and go back to hiking mountains, swimming, running agility, playing disc and being the go-anywhere dog he loves to be.”

Squid

Agility

“My dog, Squid Vicious, was diagnosed and treated for bilateral iliopsoas strains and underwent stem cell and platelet-rich plasma (PRP) treatment. After a long recovery of rest and rehabilitation, Squid made a full recovery and has gone on to have a very successful career in agility.”

Ryker

Agility

“Dr. Canapp was very thorough in his examination, diagnosis and treatment of Ryker’s MSS, which included radiofrequency treatment, platelet-rich plasma (PRP) and stem cells. Following surgery, Ryker completed about three months of rehabilitation and then three months of strength training. He is currently back to running agility. Amazingly, his weave-pole issues are resolved.”