Patient History - Canine Wellness Visit
Client Name
*
First Name
Last Name
Cell Phone (we will need to reach you to discuss the exam)
*
-
Area Code
Phone Number
What is the make, model and color of the vehicle you are in today?
*
Email
*
example@example.com
Patient Name
*
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:
Rabies
Distemper
Leptospirosis
Lyme
Bordetella
Do we have permission to update wellness testing that may be due or past due? Please select the following:
Fecal testing
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?
Please list your pet's current medications, including dosage:
Please tell us what brand of food your pet eats, as well as the amount and how often he/she is fed:
Is your dog current on flea/tick and heartworm medication?
Yes
No
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
Decline Flea/Tick
Decline Heartworm
Submit
Should be Empty: