Annual Wellness History Form

Wellness Patient Information Form - COVID

Please submit this form AFTER an appointment has been scheduled
Have you (or the person bringing your pet to the vet office) tested positive for COVID-19 within the last 10 days? or awaiting test results? *

yes no
Have you had any COVID-19 Symptoms (cough, fever difficulty breathing, etc.) within the last 10 days? *

yes no
Do you think you may have COVID-19? *

yes no
Has your pet had contact with a COVID-19 person? *

yes no
If you answered yes to any of the above questions, please call the office so we can arrange a telemedicine appointment.
Pet Owner *

First Name Last Name
Phone Number for use during vet visit *

Area Code Phone Number
Upcoming Appointment Date / Time *
Email *
example@example.com
Pet Name *
Vehicle Make/ Model /Color *
Does your pet have any chronic illnesses? *
Is your pet currently taking any medications, vitamins, supplements?
What dog food/ treats/ table food is your pet currently eating? *
How much do you feed your pet, and how often? *
What dental home care do you use (brushing teeth, food, treats) and how frequently is it done?
Do you have any concerns about your pet's weight?
Do you perceive that your pet is painful?
Have you noticed any of the following:

Increased drinking Increased urination Change in eliminations or litterbox habits Change in appetite Mobillity changes Activity Level
Is your pet *

indoor outdoor indoor/outdoor
Pet Insurance Provider
When not in COVID quarantine, tell us about your pet's lifestyle *

Social Butterfly - Doggie Daycare Outdoor Enthusiast - Lakes, Trails, Outdoor Adventures Homebody - Comfortable in their own home/yard Exercise Buff - Neighborhood walks and jogs Carefully Coiffed - grooming visits Vacationer - beach /mountain /family trips Visitor - guest at boarding facilities Explorer - long distance trips
What is your current Heartworm Preventative? *

Sentinel Spectrum Heartgard Revolution
My pet's Heartworm prevention

is up to date is past due
What is your current Flea/Tick Preventative? *

Bravecto Credelio Seresto Revolution
My pet's Flea/Tick prevention is

up to date past due
If you need a refill of preventatives, please type in the products/ amounts below.
Please perform the following services *

all needed services vaccination fecal exam 4dx testing (dogs only) Chronic Medication Blood Work Pre-Anesthesia Screening - Dentistry Pre-Anesthesia Screening - Other
Early Detection Blood Work (pets ages 3-8) recommended

please submit to the lab please call to discuss Not at this time
Senior Blood Work (pets ages 9 and above) recommended

please submit to the lab please call to discuss Not at this time
If you need a refill of prescriptions, please type in the products/ amounts below.
If you have additional information, or any questions, please use the box below
Does your pet have any food allergies or sensitivities? We love to give treats to our patients!
Does your family have any food allergies or sensitivities? We love to give treats to our patients! *
Thank you for completing our online medical history form. This will allow us to keep phone lines open during this difficult time
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Wellness Patient Information Form - COVID