Yearly Recheck Form in Lacey, WA | Dermatology Clinic for Animals

Client Information

Owner #1*

Owner #2*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home / Cell Phone*

Can we send you text messages?*

Yes
No

May we contact you by email?*

Yes
No

Email*

Driver's License

Employer

Name of Veterinary Hospital you take your pet to?

Patient Information

Name

Medications currently taking/dose/frequency

Other pets in the household

Name	Species	Breed	Age

I do / do not authorize Dermatology Clinic for Animals to obtain pictures of my pet in order to document the skin condition and /or for teaching purposes or publication.

I authorize and direct the veterinarians at Dermatology Clinic for Animals to diagnose, prescribe, perform therapeutic procedures, and/or surgery that their judgment may dictate to be advisable for the patient’s well-being. No warranty or guarantee has been made as to the result or cure. Appointment Cancellation Policy: Dermatology Clinic for Animals is committed to providing all of our patients with exceptional care. Please call (253) 596-5093 two business days prior to canceling your appointment or procedure to allow.

Appointment Cancellation Policy: To cancel appointments please call (360) 350-4756 two business days prior to canceling your appointment or procedure to allow another patient to be seen. If prior notification is not given, then prepayment for future appointments will be required. Scheduling an intradermal allergy test or video otoscopy will require a deposit of $150. Thank you for helping us continue to offer exceptional care for your pet.

Date*

Signature*

Enter the code below

Get Directions

Appointments

Stay Informed

Yearly Recheck Form

Client Information

Patient Information