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

Our Specialists

Andrew Sams, DVM, MS, DACVS

Founder & Medical Director
Orthopedic Surgery & Arthroscopy

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

Orthopedic Surgery & Arthroscopy
Sports Medicine & Rehabilitation

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

Sports Medicine & Rehabilitation

Patient Stories

Cider

Agility

“Cider has recovered so well from his procedure for medial shoulder syndrome (MSS). I can tell a huge difference! He is so grateful to be back to his very energetic, keep mommy on her toes self!”

Levy

Agility

My 6-year-old AKC FCI World Agility Team Border Collie and Silver Medalist, Leverage “Levy,” had a very complicated and extensive carpus and possible shoulder injury which required very special treatment. For several weeks I was haunted with despair and merely hoped she could just run pain- and limp-free again. Little did I know, Dr. Canapp and his team would bring my remarkable girl back to doing what she loves — agility, herding, frisbee and swimming.

Tango

Agility

“About three months after Tango placed 4th in the USDAA Cynosport Steeplechase, he developed an intermittent, slight limp in his front leg. We went to veterinarians and a specialist, but no one could tell me exactly what was wrong, even after an MRI, physical therapy, laser therapy, Adequan and Metacam. On a former client’s suggestion, we flew from Seattle to see Dr. Canapp. I got an answer right away—Tango was diagnosed with bilateral medial shoulder syndrome.”

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.”