Patient Admitting/History Recheck Form Your Name* First Last Pet Name*What condition is being rechecked today?*How long have you been treating this problem?*Are there any other concerns?*Has your pet's condition improved?* Yes NoIs your pet taking any medications?* Yes NoIf your pet is taking medications, were they given today?* Yes NoIf your pet is taking medications, list the medication name and the dosing instructions you are following. DO NOT PUT "YOU HAVE IT ON FILE!" Our doctors want to verify the doses you are giving. If your pet is NOT taking meds, put "n/a"*How do you feel the treatment(s) have been going? Any difficulties?*Has your pet been eating normally?* Yes NoHas your pet been drinking normally?* Yes NoAre there other pets at home?* Yes NoPlease list how many and what type (cat, dog, etc..)*SpeciesQuantity Add RemoveDo you need any written prescriptions or any medication filled at the time of the appointment (this includes prescription food or flea/tick prevention)?Do you authorize treatment as deemed necessary by the doctor?* Yes No Contact firstI authorize Martinez Animal Hospital to charge up to*Any expenditures over that amount require my approval.What is the name of your pet insurance provider? (Put n/a if you do not have pet insurance)*In order to treat your pet in a timely manner, it is extremely important that we are able to reach you by phone throughout the day. Please leave a number that will be answered and checked, Our first concern is for your pet.*Late appointment policy* I agree to the late appointment policy.By checking this box, you understand that if you are 10+ minutes late to your appointment, you are subject to a late appointment fee IF we can still see your patient. If we cannot see you because of your late arrival, you will be charged a missed appointment fee.No show fee* I agree to the no show feeBy checking this box, you understand that if you do not give us 24 hour notice of cancellation or the need to reschedule, you will be charged a missed appointment fee. Please note, you may be asked to pre-pay for you next appointment in addition to paying the missed appointment fee.Signature*
