First Visit FormPlease complete the FIRST VISIT FORM (below) prior to arriving at CARE.Pet owner informationPlease 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.First and Last Name:Spouse or Partner's First and Last Name:Address informationAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact informationEmail* Phone*Your Work PhoneYour Cell PhoneOther informationWhom may we thank you for your visit?Primary veterinarian informationPlease 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 NameAnimal HospitalVeterinarian's Phone NumberVeterinarian's Email AddressPet informationPlease complete the General Health information below:Pet's NameSpeciesBreedDate of Birth (approx)Sex Male FemaleNeutered or Spayed Yes NoGeneral pet conditionsWhat 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 surgeriesBesides of spaying or neutering, has your pet had any surgeries? If so, please explain what type and when:Legs and JointsHas there been any lameness? Yes NoIf yes, which leg(s) are affected? (select all that apply) Left Front Right Front Left Rear Right RearWas there any known trauma that occurred prior to you seeing lameness? Yes NoHas the patient demonstrated any difficulty on rising, climbing stairs or descending stairs? (select all that apply)RisingClimbing StairsDescending StairsDo these signs worsen or improve with exercise?WorsenImproveFood and Diet informationPlease list your pet's diet, amount and frequency:Medications and SupplementsPlease list the names, doses and length of time each medication and supplement has been given:Other observationsAre there any other observations that you would like to note at this time?CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Like Us On FacebookGet DirectionsPhoto Gallery
