Internal Medicine Recheck Form

Medical History: IM Recheck

4176 Meridian St, Bellingham, WA 98226 | Phone: (360) 758-2200 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Contact Information
Your name*
What is your preferred method of communication?*

EmailPhone Call
Your email
Phone number where you can be reached today*
(XXX) XXX-XXXX
Your pet's name*
What is your preferred pharmacy?*
Please write name and location.
Information about your pet’s current illness

Please describe any concerns or changes to your pet since your last visit.
Are there any new concerns that you have?*
Has there been any change in your pet’s previous signs?*
Have you noticed any changes in behaviour, activity, appetite, urination, drinking, defecation?*
Did you make any veterinary visits to a practice other than BBVSH since your last visit?*

YesNo
What tests were performed? *
Is your pet currently on any medications?

YesNo
Medications

Please list the medications that you are currently giving to your pet. Please include:
- Name of medication(s)
- Frequency that you are administering the medication(s)
- Strength of the medication(s)
- Number of tablets you are giving per dose
You can also upload photos, if easy & convenient:

Cancelof
What diet is your pet currently eating? *
OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us for internal medicine treatment for your beloved pet:
e.g. I searched Google for 'internal medicine vet near me'; My vet recommends you for internal medicine, I've been here before!
Could this form be better? Share your thoughts with marketing@bbvsh.com
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4176 Meridian Street

(360) 758-2200

Medical History: IM Recheck

Contact Information

Information about your pet’s current illness

Medications

Bellingham Hospital