Language
English (US)
Spanish (Latin America)
Ophthalmology Recheck Questionnaire
Please complete prior to your appointment
Your pets name
*
Owner or Agent
*
First Name
Last Name
Date of recheck appointment:
*
Best contact number on day of appointment
*
May we send you text messages at the above number?
*
Yes
No
How physically challenging is it to medicate your pet?
*
1
2
3
4
5
Easy
Difficult
1 is Easy, 5 is Difficult
Have you been able to consistently administer the medications as prescribed?
*
Yes
No
Would you like one of our technicians to provide tips / demonstrate medication administration?
*
Yes
No
Is your pet showing any signs of systemic symptoms such as vomiting, loss of appetite, excessive water intake, diarrhea that you would like to discuss with our doctor?
Is your pet currently receiving any medications BY MOUTH?
*
Yes
No
Please list all medications that are currently being given by mouth
Do you have any concerns about how your pet reacts to any of these medications? If yes, please give details.
List all EYE medications that your pet currently receives. Please fill out as much as possible. This helps us ensure our previous instructions were comprehensible
*
Please check any ongoing eye related symptoms (check all that apply):
*
Redness
Squinting
Discomfort
Loss of vision
Corneal opacity / cloudiness
Cataract
Ocular discharge
Rubbing eye(s)
NONE of these
Do you have any questions or concerns?
Optional - Submit photo(s) or video related to any questions or concerns
Browse Files
Cancel
of
Dr. Zarfoss will always discuss the most common and/or serious side effects of any medication prescribed. In addition, we are legally obligated to offer you additional drug counseling, including an additional conversation and drug insert. Please sign here that you understand that at the end of the appointment you are entitled to request additional information about any new medication prescribed.
*
Client or Agent
Clear
Submission Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: