Patient History
Wellness Exam
Guardian Name
First Name
Last Name
Cell Phone (we will need to reach you to discuss the exam)
*
-
Area Code
Phone Number
Please list the make and color of your car
*
Make and color of your car
Email
example@example.com
Patient's Name
Reason for Visit
Is your pet eating, drinking, urinating and defecating normally? If not, please explain:
Do we have permission to update vaccinations that are due or past due? These may include:
Rabies
Distemper
Leptospirosis (dogs only)
Lyme (dogs only)
Bordetella (dogs only)
Leukemia (cats only)
Do we have permission to update wellness testing that may be due or past due? These may include:
Intestinal parasite screening
Heartworm and tick disease testing
General wellness blood test/screening
Are there any issues you would like to address with the doctor during your appointment?
Please let us know your pet's diet.
Brand Name
Wet or Dry Food
Amount
Pet Food
Pet Food
Other
Is your pet (dog or cat) current on flea/tick medication?
Yes
No
If no, please indicate when the last dose of flea/tick medication was given.
-
Month
-
Day
Year
Date
Is your pet (dog) current on heartworm medication?
Yes
No
If no, please indicate when the last dose of heartworm medication was given.
-
Month
-
Day
Year
Date
Do you need refills?
6 months Flea/Tick
12 months Flea/Tick
6 months Heartworm
12 months Heartworm
Decline Flea/Tick
Decline Heartworm
For our kitty friends- does your cat go outside?
Strictly indoors
Indoor/Outdoor
Outdoor Only
Sometimes goes in the yard
RABIES RSA Verification: I swear to my knowledge that this animal has not bitten anyone in the last ten (10) days.
Agree
Disagree
Signature
Clear
Submit
Should be Empty: