Canine Risk Assessment Form (Senior)

Canine Senior (7+ years) Risk Assessment
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:
General Vaccinations

Physical Exam ($70.00)Rabies Vaccination ($35.50)DHPP Vaccination ($29.50)Bordetella Vaccination ($35.00)Canine Influenza Vaccine ($37.00)
Senior Testing

Senior Canine Wellness Comprehensive Panel ($258.00) includes CBC, Chemistry, Thyroid evaluation, Urinalysis, Accuplex, Fecal, SDMA
Individual Tests

Urinalysis ($72.00)Blood Pressure ($43.00)Schirmer Tear Test ($34.50)Accuplex (Heartworm/Tick Panel) ($62.50)Fecal Exam ($56.50)
DECLINE ALL
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 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, Frontline, Tritak, Capstar
Current heartworm preventative
ex. Trifexis, Heartgard, Revultion, Sentinel
Pet Name*
Client Name*
Breed
Age
Signature*

Clear
Should be Empty:

Canine Senior (7+ years) Risk Assessment