Patient Recheck Form

"*" indicates required fields

PLEASE NOTE: This recheck form must be submitted prior to being scheduled for your appointment. Please fill in all fields and hit "Submit" at the end. After the form is completed, a member of client services will reach out to you to schedule on our first available business day. If you need prescription refills prior to your appointment, email the service at [email protected] with all medication information (names, doses, and frequency of administration).

Thank you and we look forward to seeing you and your pet(s) again!

Date and time of appointment

Client Name*

Patient Name*

Species and Breed (if purebred)

Age/Date of birth

Sex

Neutered/Spayed? At what age?

Weight (last known, in kg)

For cats only: declawed?

1. What is the primary problem for which you are returning to us? Did it change it severity, duration, frequency and time of recovery? If yes, how?

Please describe the last incident of the problem behavior and any other incidents that you consider important.

2. Please list all medications, doses, frequency of administration, their response, and any side effects.

3. In what areas has your pet improved?

4. Has your pet developed any new behavior issues?

5. Describe the management and behavior therapy exercises you have been implementing at home and how you feel your pet is responding to them. Were any parts of the treatment plan difficult or confusing?

6. Have there been any changes in the household or routine since your last appointment? If your pet used to respond differently to one family member than other, has this changed since your last visit? Please describe.

7. Have there been any changes in your pet's medical history since your last appointment?

If yes, please ask your vet to email all pertinent records to [email protected] or fax to 706-608-8369.

Yes

No

8. Would you like to purchase medications during the appointment or would you like prescriptions to take to your local pharmacy?

Medications from UGA

Prescriptions to external pharmacy

9. What are your goals for this recheck appointment? Any additional comments?

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We’re UGA Vet Med, and our

passion powers our commitment.

501 D. W. Brooks Drive
Athens, GA 30602