Recheck Exam Admission Form

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I have NOT been in contact with an individual that has tested positive for COVID-19
I HAVE been in contact with an individual that HAS tested positive for COVID-19

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I am NOT bringing an animal into the clinic that has been around a person that has tested positive for COVID-19. Pets can act as fomites.
I AM bringing an animal into the clinic that HAS been around a person that HAS tested positive for COVID-19. Pets can act as fomites.

Name*

Age*

Please specify weeks/months/years*

Sex*

My Pet Was Initially Seen For*

Please List Medications and Doses of Medications That Your Pet Has Been on*

Do You Feel That the Condition Has Improved?*

If no to the above question, please describe in detail why the condition has not improved:

My Pet Is Eating and Drinking Normally*

My Pet Has Normal Energy Levels*

Are there additional concerns that you want addressed today?*

Do you have pet insurance, if so, what company & list the policy number:

Best phone number to contact you during the time of appointment*