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

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.”

Sig

Agility

“The surgical options were thoroughly explained, and Sig had surgery the very next day—repair of the OCD lesion in the right shoulder and radiofrequency treatment with platelet-rich plasma (PRP) and stem cell injections in the left. It has now been 11 months since surgery, and Sig is fully recovered. He has resumed agility classes and is stronger, faster and happier than ever.”

Chelsie

Agility

“Chelsie tore the subscapularis tendon in her left shoulder and had it surgically repaired by Dr. Canapp in February 2016. She returned to showing in Rally in June 2016 and went on to win the rally competition at the Cocker Spaniel national specialty in July and also compete in the agility competition there. In 2019, Chelsie was ranked 16th all-breed in AKC Rally and 8th for Cocker spaniels in AKC Preferred Agility.”

Speedoggie

Various

Our dogs do it all. Canapp keeps them running!