Behavioral Recheck Intake Form

Thank you for your continued trust in our Behavioral Medicine Department.

The information you provide in this form will help Dr. Mukhina review your pet's progress since the last appointment, assess their response to the current treatment plan, and identify any new behavioral or medical concerns to discuss during your recheck visit.

Please complete a separate Recheck Intake Form for each pet you would like to schedule for a follow-up appointment with Dr. Mukhina.

Once we receive your completed form, our scheduling team will contact you with appointment availability. Please allow up to 5 business days for a response. If you have not heard from us, please feel free to follow up.

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Has your address changed?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name:

Please select:

Primary Vet Information

If your pet is seen elsewhere for primary care & you would like to provide us with updated records since your last visit, please have your pet's veterinary records emailed to Appointments@mlahvet.com or faxed Attn: Behavioral Medicine to (856) 231-8393

Your pet's recent medical records can also be uploaded below.

Upload Medical Records

What type of Behavioral Medicine recheck appointment are you requesting:

Please note: The 8–12 week post consult follow-up is typically completed via telehealth unless otherwise directed by Dr. Mukhina.
Annual rechecks must be completed in person to maintain the veterinarian-client-patient relationship (VCPR).
For new or changing concerns, Dr. Mukhina may recommend an in-person or telehealth recheck based on your pet’s individual needs.

What are your specific goals for this recheck appointment with Dr Mukhina?

Have any new behavior problems or concerns arisen since your last appointment?

If yes, please describe:

Does your pet have a recent history of bite(s) to people or pets?

If yes, please provide a brief description of the incident:

Have any new health concerns arisen since your last appointment?

If yes, please describe:

Please include illnesses, injuries, surgeries, or other health concerns.

Please list all people and pets who currently live with your pet:

Have there been any significant changes in your pet's environment since your last appointment?

Some examples of significant changes can include:

A new family member or someone moving out
A new pet or the loss of a pet
Changes in work or school schedules
Moving to a new home
Home renovations or contruction nearby
Changes in your pet's daily routine

If yes, please describe:

How is your pet responding to the treatment plan that you are implementing?

Please list all medications and supplements your pet is currently taking, including both behavioral and non-behavioral medications. For each behavioral medication, please include the approximate percentage of improvement you have noticed since starting treatment (for example: 0%, 10%, 25%, 50%, 75%, etc.)

Rows	Medication name	Strength (mg, mg/ml)	How much is given per dose? (tablet, liquid volume)	How often? (every 8, 12, 24 hours, or as needed)	% of improvement on this medication
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10

If you have photos or videos that demonstrate your pet's problem behaviors, please attach them here. Do not attempt to obtain a photo or video that would expose you or your pet to unsafe conditions.

Please limit to 5 photos/videos maximum

Please select every day you are available for an appointment:

Thank you for taking the time to complete this form and we appreciate your continued dedication to your pet's care. The information you have provided will help Dr. Mukhina evaluate your pet's ongoing progress and ensure your recheck appointment is focused on the most important updates, concerns, and goals.

If you would like to submit a Recheck Intake Form for another pet in your household, simply click Submit below. After your submission is complete, you'll have the option to fill out a form for each additional pet.

Behavioral Recheck Intake Form

Your Pet's Information

Reason For Visit