Owner Name: Patient: Species Sex Phone NumberSecondary NumberEmail Procedure(s):Surgical Procedure Dermatology Removal of Skin Tumors and Skin Biopsy Ears Hematoma Eye Wedge Resection Cherry Eye Eye Entropion Genital/Urinary Bladder Stone Pyometra Caesarean Section Gastrointestinal Gastric Dilation volvulus Exploratory Other: Explain other: Orthopedics Referral Respiratory & Heart Heartworm Treatment Tracheal wash Soft Tissue: Mass removal Other: Explain other: Any Other Procedure not listed:Number of Skin Tumor(s) to be removed: Number of Masses to be removed: Submit Tumor for Histopathology Yes No Do you need to speak with the Doctor before surgery Yes No Owner / Agent Today's Date MM slash DD slash YYYY
