Spanish (Latin America)
Ophthalmology Recheck Questionnaire
Please complete prior to your appointment
Your pets name
Owner or Agent
Date of recheck appointment:
Best contact number on day of appointment
May we send you text messages at the above number?
How physically challenging is it to medicate your pet?
1 is Easy, 5 is Difficult
Have you been able to consistently administer the medications as prescribed?
Would you like one of our technicians to provide tips / demonstrate medication administration?
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?
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):
Loss of vision
Corneal opacity / cloudiness
NONE of these
Do you have any questions or concerns?
Optional - Submit photo(s) or video related to any questions or concerns
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
Should be Empty: