Rehab/Acupuncture Follow-up Appointment

Rehab/Acupuncture Follow-up History Form

So that our staff may prepare for your arrival, this form must be completed and submitted at least 30 minutes before your scheduled appointment time. Please call us from the parking lot when you arrive, and remain in the parking lot during your appointment (unless other arrangements are made with the doctor).
Your pet's name *
Your Full Name *

First Name Last Name
Cell phone number where we can reach you during your appointment *
Address (if changed since last visit)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Your Scheduled Appointment *

Month Day Year
Date
Is your pet currently taking any medication, parasite prevention, supplements, or vitamins? *

Yes No
Please list all medications, parasite preventives, supplements, and vitamins your pet is currently taking.
Does your pet need any medication or prescription diet refills today? *

Yes No
Does your pet have allergies to any medication, vaccine, or foods? *

Yes No
Can your pet have our treats while here (may include liver treats, EasyCheese, etc). *

Yes, any treats are fine No, my pet has treat restrictions (please note below)
Please list all of your pet's known allergies or treat restrictions:
Please list any diet or medication changes since the last visit
How is your pet doing since the last visit? Any improvements? Any new or ongoing concerns? What is the current level of activity (length of walks/activity, etc)? *
Do you have any other concerns regarding your pet or any specific questions for the doctor?
Please verify that you are human *
Should be Empty:

Rehab/Acupuncture Follow-up History Form