Recheck admitting Name(Required) First Last Pet Name(Required)What condition is being rechecked today?(Required)How long have you been treating this problem?(Required)Have you had any issues providing the recommended home care? (medicating, low activity, isolation, etc.)?(Required)Has your pet’s condition improved?(Required)Is your pet experiencing any of the following symptoms? If your pet is currently experiening symptoms, it may be best to reschedule your appointment. Please call our office to discuss this further.(Required) Vomiting Diarrhea Coughing Sneezing Lethargy Loss of appetite Increased water consumption Inappropriate urination/bowel movements Weight fluctuations Changes in eating habits Trouble chewing Change in sleeping habits Waking in the middle of the night Restlessness Lameness in any limbs Trouble walking Pain getting up Unwillingness to go for walks or play Unusual vocalizations Boredom Anxiety, fear or stress Disorientation or balance issues Change in social habits Seizures Other (Please Specify Below}) NoneIf your pet is experiencing any symptoms, please provide more details here: (how long, how often, how bad, etc.)(Required)Is your pet currently taking any medication? Please list the medication, dose and time last given. Please do not write "On File". We need to verify that the medications you are actually giving your pet matches what we have on file.(Required)MedicationDoseTime Last Given Add RemoveIs there anything else you feel we need to be aware of?I agree to pay all charges for services provided by Martinez Animal Hospital upon discharge of my pet. Payments can be made by most major credit cards, Care Credit or cash. A credit card processing fee of up to 3% will be applied to all transactions made using credit/debit cards.(Required) I UNDERSTANDI understand and accept the clinic's cancellation policy, which requires a minimum of 24 hours' notice for cancellations; otherwise, a cancellation fee may apply.(Required) I UNDERSTANDI acknowledge the clinic's late policy, which states that while efforts will be made to accommodate appointments, if I am more than 10 minutes late, Martinez Animal Hospital may not be able to provide services, and a $10 late fee may apply.(Required) I UNDERSTANDFor inpatient appointments: If we find fleas on your pet during their hospitalization, we will administer CapStar flea treatment. You are responsible for the cost of treatment.(Required) I UNDERSTANDFor inpatient appointments: 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(Required)Signature(Required)
