Canine Recheck Form

The information you provide below will be used during your consultation to develop a diagnosis and plan of treatment. Please fill it out as completely as you can. All information will be held in strict confidence and will not be released to any third party without your written consent.

Please submit this form at least 2 business days prior to your dog’s appointment date

Today's Date*

Your Contact Information

Name*

First NameLast Name

Preferred Pronouns

Spouse / Partner Name

First NameLast Name

Preferred Pronouns

Home Phone Number*

Cell Phone Number*

Work Phone Number

Fax Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

How best do you learn new information?

VerbalVisualBoth

Your Family Veterinarian's Contact Information

Family Veterinarian*

Hospital Name*

Hospital Address*

Veterinarian's Phone Number*

Do you authorize us to send a summary of the consultation to your family veterinarian?

YesNoI would like to discuss this further at the consultation.Other

Your Dog's Information

Dog's Name*

Dog's Breed

Dog's Birthdate*

Dog's Current Weight*

Sex*

MaleFemale

Spayed or Castrated?*

YesNo

Age at which Spayed or Castrated?*

Color*

% of time indoors*

% of time outdoors*

Of total time spent indoors how long is the dog in a crate?*