This is for requesting a routine recheck or drop off appointment. If this is an URGENT matter please contact your foster care liaison for immediate assistance. For which CHS location are you fostering?* Newington, 701 Russell Road Waterford, 169 Old Colchester Road Westport, 455 Post Road East What kind of support services are you requesting?* Routine recheck Drop off appointment In a couple of words, explain what needs routine rechecking: CONTACT INFORMATIONToday's Date* MM slash DD slash YYYY Volunteer Name:* Mr.Mrs.MissMs.Dr.Prof.Rev.Mx.None Prefix First Last Primary Phone:*Secondary Phone:Email:* Preferred method of contact:* Phone Email PET INFORMATIONFoster Pet(s) Name(s):* Age or DOB:* Species:* Dog Cat Rabbit Guinea pig Ferret Hamster Gerbil Rat Mouse CASE SPECIFICSPlease describe the issue(s) requiring recheck. Be specific:How long has this problem been present? Has the problem been getting worse? Yes No Is this pet on any medication(s) or special diet? Yes No Please list the medications, including dosage, and/or special diet: Request An AppointmentPlease select a preferred and an alternative appointment date and time from the following options only: Daily - 9:30 am, 2pm, 2:30pm or 3pm. Preferred appointment date:* MM slash DD slash YYYY Preferred appointment time:* : Hours Minutes AM PM AM/PM Alternative appointment date:* MM slash DD slash YYYY Alternative appointment time:* : Hours Minutes AM PM AM/PM CAPTCHA
