Drop Off Form

Potomac Animal Wellness Services

4618 Indian Head Hwy Indian Head, MD 20640 Phone Number:301-743-5411
Patient Drop Off History Form
Today's Date

MonthDayYear
Date
Your name
Your Pet's Name
We will need to be able to contact you or someone with permission to make medical and financial decisions. Who will we be speaking with?
1st choice phone number
2nd choice phone number
Reason for visit:
Vaccines: Check all that you would like done (*required for boarding)
For dogs:

Rabies*DHPP*Bordetella*Canine Influenza*LymeLeptospirosis
For cats:

Rabies*FVRCP*Feline Leukemia
Additional testing/ diagnostics

Fecal test*Heartworm/ Lyme/ Ehrlichia/Anaplasma test(dogs only)Feline Leukemia/FIV/Feline Heartworm (cats only)
Other bloodwork:
Other services: Are there any other services that you would like done while your pet is here today?

Anal Gland ExpressionNail trimMicrochipBath
Pet's Medical History
What diet is your pet eating?
When did your pet last eat?
Has your pet ever had an adverse reaction to any medications?
Has your pet ever had an adverse reaction to any vaccines or any procedure? If yes, please describe.
What heartworm preventative is your pet on?
What flea/tick preventative is your pet on?
Do you need a refill on any of your preventative medications?

Please list any medications that your pet is taking.

Have you noticed any changes or do you have any concerns about any of the following in your pet?

Eating more/lessWeight gainVomitingDifficulty risingMassesDrinking more/lessWeight lossDiarrheaScooting rearHair lossBad BreathUrinating more/lessItching/ScratchingShaking headLimping
Are there any other concerns that you may have that are not listed above?
Please describe what you have been seeing, include how long you have noticed the concern and how it has progressed over time. How frequently is it happening?
Is this the first time you've noticed this issue?
Have you tried any treatment? Did it help?
Should be Empty:

Potomac Animal Wellness Services