Canine Risk Assessment Form (Adult)

Canine Risk Assessment Form (Adult)
I elect for the doctor or technicians to administer the following services for my pet:

*Note that no dog shall receive a DHPP vaccination without physical examination unless authorized by attending DVM.*
Doctor is authorized to proceed with services based on his/her recommendation
OR check those that apply:
Physical Exam ($70.00)Rabies Vaccination ($35.50)DHPP Vaccination ($29.50)Bordetella Vaccination ($35.00)Canine Influenza Vaccine ($37.00)
Adult Canine Wellness Basic Panel ($168.00) includes CBC, Chemistry, Urinalysis, Accuplex, Fecal, SDMA
Accuplex (Heartworm/Tick Panel)($62.50)Fecal Exam ($56.50)
*Yearly heartworm testing is required to purchase preventatives and to ensure your pet is free from adult heartworms. Annual testing ensures that an infection is caught in time to effectively manage it.
Help us learn more about your dog by checking all of the following that apply:

I take my pet on hiking, hunting, or camping tripsMy dog goes for controlled walks with me in the neighborhoodMy dog attends dog shows, field trials, obedience, agility competitions in stateMy dog attends dog shows, field trials, obedience, agility competitions out of stateMy dog is retained in the yard by a fence/invisible fenceMy dog goes to the park and plays with other dogsMy dog is indoors most of the time and only goes outside in the backyardMy dog goes for a run by himself in the neighborhood dailyMy dog visits or lives on a farm or other rural facilityMy dog goes to the groomer regularlyMy dog boards at a kennel when we go away on vacation
My dog has been diagnosed with chronic disease(s).
My dog is on the following medications:
My dog's current diet:
ex. Pedigree, Pro-plan
Current flea/tick preventative
ex. flea collar, Nexgard, Bravecto
Current heartworm preventative
ex. Trifexis, Heartgard, Revultion, Sentinel
Pet Name*
Client Name*
Breed
Age
Signature*

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