Today's Date
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Date of Appointment
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Your Name
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Pet Name
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Email
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Cell Phone (preferred)
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Please make sure this is the number for whomever is authorized to make medical and financial decisions for the patient.
Secondary Phone Number
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Area Code
Phone Number
Reason for Visit (check all that apply)
Preventive Care
Illness
Injry
Are there any concerns for: (check all that apply)
Eating
Excessive Sleeping
Itching/Scratching
Shaking Head
Skin Masses/Lesions
Drinking
Weight Loss
Difficulty Rising
Vomiting
Urination Issues
Bad Breath
Weight Gain
Scooting
Diarrhea
Behavioral Problem
Please give history on concerns listed above
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Has your pet ever had an adverse reaction to any medication(s), vaccine(s), or procedure(s)?
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No
Yes
If yes, please describe
Is your pet taking any medications?
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No
Yes
Is yes, what?
Do you need medication refills? Please enter what medications need to be refilled. (Ex: Apoquel, Trazadone, etc )
Which vaccines does your pet need to have administered during today's visit :
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Bordetella
Leptospirosis
DHPP
Rabies
Lyme
Canine Influenza
No vaccines to be administered during visit
Please indicate if you would like your pet to receive pre-medication prior to vaccinations. Although reactions to vaccines are relatively low, there is always a possibility for your pet to react whether or not they had symptoms or issues in the past. We offer a diphenhydramine injection prior to vaccination(s) to minimize the chance of reaction. If your pet has had any reactions in the past, then we strongly recommend this injection. Other medications or treatments may be needed if your pet has a vaccine reaction.
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Yes (additional charge)
No
What other preventive care services does your pet require during today's visit :
Annual heartworm and tick borne disease screening
Annual intestinal parasite screening
Annual canine health screening (full panel bloodwork)
Other
Would you like a Microchip implanted?
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Yes
No
Already microchipped
How many doses of heartworm prevention does your pet need refilled at today's visit?
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6 doses of Sentinel
6 doses of Simparica Trio
12 doses of Sentinel
12 doses of Simparica Trio
1- 6 month heartworm prevention injection (Proheart 6)
1-12 month heartworm prevention injection (Proheart 12)
I decline to purchase any prevention at today's visit.
My preferred brand is not one listed, please send me a link to your online pharmacy to purchase my refill.
Other
How many doses of flea/tick prevention does your pet need refilled at today's visit?
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6 doses of Simparica
6 doses of Simparica Trio
12 doses of Simparica
12 doses of Simparica Trio
I decline to purchase any prevention at today's visit.
My preferred brand is not one listed, please send me a link to your online pharmacy to purchase my refill.
Other
Does your pet need a nail trim during today's visit?
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No
Yes (additional charge)
Does your pet need an anal sac expression during today's visit?
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No
Yes (additional charge)
Please confirm payment option has been arranged prior to appointment :
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Credit Card (card must be stored on file PRIOR to appointment
Other
All fees are due at the time services are rendered. I assume responsibility for all charges incurred in the care of my/our animal(s). I also understand that these charges will be paid in full at the time of release and that a deposit may be required for surgical treatment. Any unpaid balance will be sent to collections, for which I agree to reimburse Advanced PetCare of Oakland the fees of any collection agency, which may be based on a percentage of 32% of the total amount plus 7% interest, as well as all costs and expenses, including reasonable attorney's fees we incur in such collection efforts.
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I agree to the above terms & conditions *
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