Medicine Recheck Form Medicine Recheck Form - Hunt Valley Name * Name First First Last Last Email * Pet's Name * Your pet is being seen today to have a diagnostic procedure/testing or re-evaluation. In cases requiring abdominal ultrasound, it is necessary to clip hair on your pet's abdominal area. How has your pet been doing? * Please describe the following Activity * Appetite/Thirst * Vomiting * Diarrhea * Coughing * Please list all medications your pet is currently taking. Please include medication name, dose (mg), number of times given per day, and last dose (date/time). * Do you need any medication refills? If so, please include the medication name and the pharmacy name/contact information. * What diet does your pet eat? * When did your pet last eat? * Name of contact person * Name of contact person First First Last Last Phone of contact person * I grant AVIM&O, its representatives and employees the right to take photographs of my pet and me. I authorize AVIM&O, its assigns and transferees to copyright, use and publish the same in print and/or electronically. Yes No If you are dropping off for the day, please be aware that delays occur in procedures and discharges due to emergencies. Please allow for extra time when picking up your pet. We will do our best to accommodate you as quickly as possible. Thank you for understanding. Signature * signature keyboard Clear Today's Date * Captcha Submit If you are human, leave this field blank.
