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Owner/Caregiver information
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Name
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First
Last
Address
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State
Zip Code
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Primary Contact Phone Number
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We will call the number on top with updates ext.
Secondary Phone Number
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Email
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Preferred form of communication
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Phone call
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Referring Veterinarian Name/ Hospital
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Referring Veterinarian Phone Number
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Address
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City
State
Zip Code
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Patient information
Pet's Name
*
Breed
*
Gender
*
Please Select
Male
Female
Male Neutered
Female Spayed
Age
*
Date of birth
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Current problem with your pet
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Current Medications
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Known Allergies or Reactions to Drugs
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Duration of problem
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Please Select
Less than 24 hours
1-7 days
1 week/ less than 1 month
1 month or greater
unknown
Your First Appointment
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I already have an appointment scheduled
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Additional Comments about your pets condition
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Authorization Release
Resurge Veterinary Surgical Specialists and Rehabilitation LLC may use information from patients for purposes such as education and marketing materials. Examples: Continuing education and/ or social media.
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use of my pet's first name, photograph and clinical information on the Resurge website, social media, or within informational pamphlets. Under no circumstances will my name, my personal or financial information be shared through these media sources.
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Home
Services
Veterinary Diagnostics
Surgery
Neurology
Platelet Rich Plasma (PRP)
Physical Rehabilitation
Hyperbaric Oxygen Therapy
Acupuncture and Traditional Chinese Medicine
About
Contact
Blog
Client Registration Forms
Veterinary Referral Information
Request an Appointment
Refill a Prescription