We ask that you either fill out the Recheck Form below and send it to us electronically (submit) or download it below and complete the form and email it to us at info@thesamsclinic.com for your pet’s appointment.

Please fill out the forms prior to the appointment.

Orthopedic Recheck Form

IF YOUR PET IS EXPERIENCING ANY vomiting/diarrhea/coughing/sneezing PRIOR TO THE APPOINTMENT PLEASE CALL IMMEDIATLY AS WE MAY HAVE TO RESCHEDULE THE APPOINTMENT

Date

YYYY

Name *

Client first and last name

First Name

Last Name

Pet's Name *

First Name

Last Name

Phone *

Best contact number for today's visit

(###)

###

####

Reason for Recheck Appointment? *

Post Surgery Follow up

Annual Recheck

Rehab Follow Up

Orthopedic Recheck

Has your pet had any new X-rays or treatments at another hospital since their last visit to The Sams Clinic? (WE KINDLY ASK YOU TO CONTACT EACH LOCATION TO REQUEST X-RAYS AND RECORDS TO BE FORWARDED TO info@thesamsclinic.com PRIOR TO YOUR APPOINTMENT) *

If yes, please provide the hospital location(s) and date(s) imaging was performed?

Text

Has your pet had any new blood work performed since your last visit to The Sams Clinic? *

If yes, please provide hospital location(s) and date(s) diagnostics were performed

Text

Has your pet been showing signs of lameness and if so which limb(s)? *

Please pick one

Is your pet doing well? *

What is your pet's current level of activity/exercise? *

What are your goals for today's appointment? *

Has your pet been on ANY of the following anti-inflammatory medications? *

Metcam/Meloxicam/Meloxidyl

Rovera/Rimadyl/Carprofen

Galliprant

Previcox

Other NSAID

NONE

If Yes to the above question, please answer the following: *

Write N/A if does not apply 1. What is the dose in milligrams (mg)? 2. What is the frequency? 3. Duration of treatment (how long was the treatment prescribed)? 4. When was the last dose administered?

Has your pet been on ANY of the following corticosteroids? *

Prednisone

Prednisolone

Cortisone

Temaril-P

None

If yes, to the above question, please answer the following: *

Type N/A if does not apply 1. What is the dose in milligrams (mg)? 2. What is the frequency? 3. Duration of treatment (how long was the treatment prescribed)? 4. When was the last dose administered?

Please list all other medications/supplements/injections your pet has had within the last 30 days: *

Has your veterinarian diagnosed your pet with any new medical problems or health conditions since your last visit to The Sams Clinic? *

If yes, please provide details

Does your pet have any new health or orthopedic problems since your last visit to The Sams Clinic? *

*Note: If your pet has been recently diagnosed with an infectious disease we will ask for proof of negative lab results or clearance from your primary vet before we can see your pet.

If yes to the above question, are those medical issues currently being treated? *

Write N/A if does not apply

Has your pet had any vomiting, diarrhea, coughing or sneezing in the last 30 days? *

If Yes, please describe:

Does your pet have any known allergies or sensitivities to foods or medications? *

If Yes, please describe:

Does your pet have any known allergies or sensitivities to sedation or anesthetic drugs? *

If yes, please provide details

Has your pet ever had any problem with sedation or while under general anesthetic? *

If yes, please provide details

Will your pet have anything to eat on the day of the appointment? If Yes, what time? *

**Note: Patients must have fasted 4 hours prior to appointment if any diagnostics are recommended the day of the appointment.

**IF YOU ARE DROPPING OFF YOUR PET WE WILL CALL PRIOR TO ANY DIAGNOSTICS UNLESS CONSENT TO PROCEED WITHOUT NOTIFICATION IS GIVEN AT TIME OF DROP OFF** I assume all financial responsibility for the fees related to these procedures and will provide full payment at the time my pet is discharged from The Sams Clinic

The doctors and/or technicians may need to administer a sedative, take x-rays, and/or perform blood work to diagnose your pet’s ailment. Do you consent to these procedures *

Yes

If fields are left empty the form will not submit and text will turn red to complete.

Have you had a fever or any symptoms of illness in the last 14 days? Have you been exposed to anyone testing positive for Covid-19 in the last 14 days?

Please answer yes or no to both questions *Symptoms of the illness include (but is not limited to) Cough Fever (> 100 F) Sore throat Headache Congestion GI issues (vomiting, diarrhea, nausea) Body aches Loss of smell or taste Any general feeling of illness

Signature *

First Name

Last Name

Thank you!

The Sams Clinic

Location
489 Miller Avenue
Mill Valley, CA 94941

Phone: (415) 380-0500
Fax: (415) 380-0504

Email: info@thesamsclinic.com

Clinic Hours

Monday:   8:00 a.m. - 5:00 p.m.
Tuesday:   8:00 a.m. - 5:00 p.m.
Wednesday:   8:00 a.m. - 5:00 p.m.
Thursday:   8:00 a.m. - 5:00 p.m.
Friday:   8:00 a.m. - 12:00 p.m.
Saturday:   Closed
Sunday:   Closed