Client_Syringomyelia_Screening_RegistrationPlease Select- Select -Mr.Mrs.Ms.Dr.First NameMiddle InitialLast NameCo Owner First NameCo Owner Middle InitialCo Owner Last NameAddressAddress Line 1Address Line 2CityStateZip CodeHome PhoneCell PhoneFaxEmailYour EmployerEmployer PhoneCo-Owner's EmployerCo-Owner's Employer PhoneHow did you hear about our Syringomyelia MRI Screening services?What is the name of your primary veterinarian and clinic?Why have you elected your pets to undergo this screening?Are you affiliated with a breed-specific organization? Yes NoIf so, which organization?Who is the Contact Person there?Organization Contact PhoneOrganization Contact EmailPets NameBreedColorSexDate of BirthAgeLast Distemper Vaccination DateRabies DateHas your pet been neutered or spayed? Yes NoHas your pet eaten in the last 12 hours? Yes NoAre you aware of any underlying medical issues present in your pet? Yes NoIf YES to above question, please explainPlease check any of the following items that your pet may have Avid Chip (ID microchip inserted under the skin) Metal Dental Work (e.g. crowns) Pacemaker Orthopedic implants Birdshot Stainless Steel Suture Surgical Staples Other (please explain below)If other, explain:To my knowledge my pet has no implants or metallic devices in his/her body. Please initialI have read and understand the Syringomyelia Screening Guidelines and acknowledge that this is an elective procedure intended for pets for the purpose of breeding. Please initial A physical examination and Chem/CBC lab test has been performed on my pet by my veterinarian in the last 10 days. The pre-anesthesia physical examination and laboratory findings form has been provided to the VNC Yes NoIf answer to above question is NO, I authorize the VNC doctor to perform a physical examination and pre-anesthetic laboratory panel prior to the procedure for an additional fee. Please initialI have provided copies of my pet's microchip documentation Yes NoI have provided copies of my pet's tattoo information Yes NoI have provided copies of my pet's AKC (or other breed specific) registry documentation Yes NoI understand that if the VNC doctor, upon examination, finds any signs of neurological deficits or any indication that my pet may be unsafe for anesthesia, the procedure will need to be cancelled. Please initial In order to ensure you have a backup of your submission, please print and/or email a copy of this form. To print a copy of this form: Prior to submission, click the print function from your browser. To receive a confirmation copy of this form via email: Enter your email address in the Email Address box If you do not receive the confirmation copy shortly after submission, please contact us. Your EmailSubmit Form
