First Visit Form First Visit Form Pet Owner Information Please note that a $100 deposit is required to schedule an Initial Rehab Exam and that 48 hours' notice is required for cancellation or rescheduling or the deposit is forfeited. Owner's Name * Owner's Name First Name First Name Last Name Last Name Spouse or Partner's Name Spouse or Partner's Name First Name First Name Last Name Last Name Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Phone * Work Phone Cell Phone Whom may we thank you for your visit? Primary Veterinarian Information Please provide contact information of your pet's primary veterinarian so we may keep them posted about treatments provided to your pet by CARE: Veterinarian's Name Animal Hospital Veterinarian's Phone Number Veterinarian's Email Address Pet Information Please complete the General Health information below: Pet's Name * Species * Breed * Date of Birth (approx) * Sex * Male Female Neutered or Spayed * Yes No General Pet Conditions What is the primary reason for your visit? * Please note changes to any of the following - Food or Water Consumption; Urination; Defecation; Weight; Vision; Hearing; Activity Level; and/or Sleeping Pattern: History of Surgeries Besides of spaying or neutering, has your pet had any surgeries? * Yes No If so, please explain what type and when Legs and Joints Has there been any lameness? * Yes No If yes, which leg(s) are affected? (select all that apply) Left Front Right Front Left Rear Right Rear Was there any known trauma that occurred prior to you seeing lameness? Yes No Has the patient demonstrated any difficulty on rising, climbing stairs or descending stairs? (select all that apply) Rising Climbing stairs Descending stairs Do these signs worsen or improve with exercise? Worsen Improve Food and Diet information Please list your pet's diet, amount and frequency: Medications and Supplements Please list the names, doses and length of time each medication and supplement has been given: Other Observations Are there any other observations that you would like to note at this time? Captcha Submit If you are human, leave this field blank.
