Patient History - Canine Wellness Visit
Cell Phone (we will need to reach you to discuss the exam)
What is the make, model and color of the vehicle you are in today?
Reason for Visit
Is your dog 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:
Do we have permission to update wellness testing that may be due or past due? Please select the following:
Heartworm and tick disease testing
Comprehensive Wellness testing that includes intestinal parasite screen, heartworm/tick disease screen, urinalysis, full-body chemistries
Are there any issues you would like to address with the doctor today?
Is your dog current on flea/tick and heartworm medication?
If no, when was the last dose given?
Do you need any medication refills today? Please select one of the below or list in "Other".
6 months Flea/Tick
12 months Flea/Tick
6 months Heartworm
12 months Heartworm
Should be Empty: