Two Week Recheck Check In Form

This form is for clients who have scheduled a recheck appointment with Chester Valley Veterinary Clinic within two weeks from the last appointment.

Name *

Email *

Phone *

Has your pet been seen previously by a veterinarian? *

Pet's name *

Species *

Reason for recheck appointment *

Current medications and dosage and frequency *

Any difficulties in giving medications? *

Have you noted any improvement in your pets condition? *

Have you noticed any worsening in your pets condition? *

Do you have any other concerns in regards to your pet? *

Any additional information you feel is important for us to know? *

Primary contact for visit *

Phone *

Photo/video release: I hereby grant permission to the rights of my pet’s image, likeness and sound of his/her voice as recorded on audio or video without payment or any other consideration to Chester Valley Veterinary Hospital. I understand that my pet’s image may be edited, copied, exhibited, published or distributed and waive any right to royalties or other compensation arising or related to the use of my pet’s image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. *

Permission granted
Permission denied

Acupuncture Authorization: Pet acupuncture can be used to treat a host of issues, from pain, appetite stimulant, GI concerns, URI concerns and even sedation and anxiety. Acupuncture is the process of carefully placing special needles at certain points on the body in order to stimulate the nerves and lymphatic systems, as well as create complex interactions with the fascia layer and release of different chemicals and hormones in the body. This results in reduced pain and inflammation, and increased nerve function. Some patients may be slightly sore after treatment. It is not uncommon to also be more sedate after a treatment. I approve/decline the use of simple acupuncture as deemed fit for my pet by Dr. Tobiason. *

Approve
Do Not Approve

Treatment authorization/payment authorization: I hereby authorize Chester Valley Veterinary Hospital’s doctor(s) and staff to examine my pet(s) and to discuss findings with me or an authorized representative. I understand that I am entitled to an estimate of charges for the care and treatment of my pet(s). I am also aware that regardless of my decision to proceed with the estimated treatment or not I am responsible for an exam fee. I hereby consent to the care and treatment of my pet(s) by the staff at Chester Valley Veterinary Hospital. I give my permission to the administration of anesthesia and surgical procedures as seen fit by the physical in the event of an emergency as well as in the treatment of my pet(s). I understand that an itemized receipt will be presented to me upon the release of my pet(s). I take full financial responsibility of all incurred charges for my pet(s). I also understand that full payment is expected before said pet(s) is released to me. I fully understand that any pet(s) brought to Chester Valley Veterinary Hospital by the above person/persons or authorized representative will be considered abandoned, if the animal(s) is not collected within 10days of written notice to the above address. Upon which time Chester Valley Veterinary Hospital has the rights to adopt it out, sell, or euthanize without prejudice to its claims for fees or services rendered. *

I have read and understand

No show/cancellation policy: I hereby understand that Chester Valley Veterinary Hospital requires all appointments be canceled 2 hours prior to your scheduled appointment. Failure to call and cancel an appointment or arriving 5 minutes late to an appointment will be deemed a “No Show.” A cancellation without appropriate notice or no-show appointment will incur a fee at Chester Valley Veterinary Hospital’s discretion and can result in the refusal of service at this practice. *

I have read and understand

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Digital signature *

Date *