Cell Phone (we will need to reach you to discuss the exam)
Please list the make and color of your car
Make and color of your car
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:
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.
Wet or Dry Food
Is your pet (dog or cat) current on flea/tick medication?
If no, please indicate when the last dose of flea/tick medication was given.
Is your pet (dog) current on heartworm medication?
If no, please indicate when the last dose of heartworm medication was given.
Do you need refills?
6 months Flea/Tick
12 months Flea/Tick
6 months Heartworm
12 months Heartworm
For our kitty friends- does your cat go outside?
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.
Should be Empty: