510-548-6684
1048 University Avenue, Berkeley California
ER Visit Request
Specialty Appointment Request
ER Visit Request
Specialty Appointment Request
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Recheck questionnaire
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Ophthalmology Recheck Questionnaire
Please complete prior to your appointment
Your pets name
*
Your name
*
First Name
Last Name
Date of recheck appointment:
*
Is your pet currently receiving any medications BY MOUTH?
*
Yes
No
List all ORAL medications that your pet currently receives. Please fill out as much as possible.
List all EYE medications that your pet currently receives. Please fill out as much as possible. This helps us ensure our previous instructions were comprehensible
*
Did you bring your pets medications with you today?
*
Yes
No
Have you administered eye medication in the last 2 hours?
*
Yes
No
If so, which one(s):
Please check any ongoing eye related symptoms (check all that apply):
*
Redness
Squinting
Loss of vision
Corneal opacity / cloudiness
Ocular discharge
Rubbing eye(s)
NONE of these
Other
Please list any questions or concerns you would like to address with the ophthalmologist:
Optional - Submit photo(s) or video related to any questions or concerns
Drop files here to upload
Browse Files
Cancel
of
Cancel
of
The ophthalmologist will always discuss the most common and/or serious side effects of any medication prescribed. In addition, we are legally obligated to offer you additional drug counseling, including an additional conversation and drug insert. Please sign here that you understand that at the end of the appointment you are entitled to request additional information about any new medication prescribed.
*
Client or Agent
Submission Date
-
Month
-
Day
Year
Date
Submit
Should be Empty:
