Canine Preventive Visit

Canine Preventive Visit
Owner's Name*

First NameLast Name
Pet Name*
Phone # for call or text during pet's visit

Area CodePhone Number
In last 2 weeks, has pet had any potential exposure to person with symptoms of or that has been diagnosed with COVID19? *
Diet- Brand, Amount, Frequency; Treats? People food?*
Apptite*

NormalIncreasedDecreasedUnsureOther
Any change in thirst or urination?*
Heartworm Prevention Product*

Heartgard PlusSentinelRevolutionNoneOther
Last given/applied

MonthDayYear
Date
Number of doses needed today to continue monthly year-round (best for your pet!)*
Flea &Tick Control Type*
Last given/applied

MonthDayYear
Date
Number of doses needed today to continue monthly year-round (best for your pet!)*
Best deal is to get multiple doses of Heartgard and Nexgard together (12&12 qualifies for free dose of Nexgard and $75 off!)
Please list any other medications or supplements*
New Lumps or Bumps - if so where and how long?*
Any signs of parasites?*
Non- Core Vaccines you are interested in possibly updating today (if due or would like to start)*

Bordetella (kennel cough) - dogs that go to boarding, grooming, dog parks, etcLyme - any potential tick exposure, places where deer have beenI do not want either of the Non-Core Vaccines
For dogs over 9 months of age: If your dog is due for heartworm/tick (blood parasite) test & intestinal parasite screen (stool) test today, we are able to pass along a great deal from our lab for a discounted preventive panel that includes Complete Blood Count and Metabolic Panel (Chemistry):*

Yes, Basic (Adult) Panel for $63Yes, Premium (Senior) Panel for $129 (also includes urinalysis and T4 thyroid)No panel today
Any medical or behavioral questions or concerns today?*
If pet is new to you or to us here at Log Cabin: How long have you had pet, and where did you get pet from?
Have you or anyone in your or pet's household had COVID19 or symptoms of illness (cough, fever, loss of taste/smell, sore throat, chills, difficulty breathing...) within the past 2 weeks?

YesNoPrefer not to answer
How do you intend to pay for the visit?*
Contactless Payment preferred- we can send you a secure link to your cell phone that you can pay yourself with your card directly
Should be Empty: