Patient Recheck Form - East Tennessee Veterinary Ultrasound

Name*
First Last
Phone*
Email*
How do you prefer to be contacted?*
- Phone
- Text
- Email
Patient Information
Pet's Name*
Pet's age*
Breed*
Current weight (if known)
Name of Regular Veterinarian*
Date of Appointment*
MM slash DD slash YYYY
Reason for recheck*
Have there been any health changes with your pets since the last visit? If Yes, please describe
Current Diet including brand names and any treats.*
Has your pet been seen by your primary veterinarian, an emergency practice or a specialist since your last visit with us? If so, please provide the name(s) of the practice so that we may contact them for your pet’s medical records. Alternatively, you may request that your pet’s records be emailed to us at contact@etvetus.com.
please email any medical records or test results to contact@etvetus.com. Alternatively, you may also contact your regular veterinarian’s office to request that your pet’s records be emailed to us.

Pet Medication List

Please list all medications, supplements, and preventives your pet is currently taking. Provide the name, strength or concentration (if a suspension or transdermal), how much is given, route, and frequency of administration.

Feel free to take pictures and/or bring your pet’s medications to the appointment if there are any questions.

EXAMPLES

Name	Strength or Concentration	How Much Given	Route	Frequency
Pimobendan	5 mg	1 tablet	by mouth	every 12 hours
Methimazole	5 mg/ml suspension	1/2 ml	by mouth	every 12 hours
Simparica Trio	44–88 lb size	1 tablet	by mouth	once monthly

Current medications and supplements:*
Is there anything else you would like us to know about your pet?
If you would like to send us an image of your pet for the medical record, please upload it here.
Max. file size: 128 MB.
Payment Options
All payment is due at the time of service. For your convenience, we accept cash, all major credit cards, cashier’s checks and Care Credit Financing (6 month Financing Terms Only). We are also pleased to offer a 2% cash discount. We no longer accept personal checks. If assistance is needed with financial arrangements please contact us by phone or email.
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Patient Information

Pet Medication List

EXAMPLES

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