Wellness Clinic Questionnaire

Today's Date *

Date

Your Name: *

First Name Last Name

Pet's Name: *

Please send any prior medical/vaccination records to: staff@integrativepets.com

Which services are you interested in for this pet? (check all that apply) *

What diet and treats do you feed your pet (please be specific as possible: Name brand, protein - Chicken, beef, fish, etc., Type - kibble, canned, raw, dehydrated) *

Has your pet ever had a reaction to any vaccines, medications, foods, etc? *

YES NO

If Yes, please list what caused the problem and what issues occurred:

Is your pet current on heartworm prevention? *

YES NO

When was your pet's last dose? (please estimate if unknown) *

What brand of heartworm prevention do you use/prefer? *

Is your pet current on flea and/or tick prevention? *

YES NO

When was your pet's last dose? (please estimate if unknown) *

What brand of flea/tick prevention do you use/prefer? *

Please list any other medications and/or supplements you give your pet: (please enter "none" if no other meds are given) *

Has your pet been ill (anorexia, lethargy, vomiting, diarrhea, coughing, scratching, skin/ear infections, etc.) within the last 2 weeks? *

NO YES

If yes, please describe the issues and when they occurred: (please type "no issues" if not applicable) *

Please read/acknowledge and sign below to verify consent for services:

EXAM: I understand that all Wellness Clinic services are for well pets only and only include a brief exam. If I am concerned about any health issues, I will be directed to my regular full-service veterinarian.

VACCINES: If I am requesting vaccines, I am confirming that my pet has shown no signs of any type of illness or parasitic activity within the last 2 weeks of clinic date as IVS does not recommend vaccines be administered if these issues are occurring due to possible health risks. I also understand that IVS does not recommend giving multiple vaccinations at once to and recommends waiting 3-4 weeks in between vaccinations.

TITER TESTING: I am aware that any titer antibody testing can take 3-4 weeks before results are received. I also am aware that currently the state of Texas does not accept Rabies titer testing in lieu of a rabies vaccination.

MEDICATIONS: I am aware that IVS utilizes an online pharmacy (Vet's First Choice) for most of their prescription medications, and that I will be able to request and pay for medications online, and they will be sent directly to my home.

PAYMENT: I am aware that payment is due in full at the time services are performed and that debit/credit cards are the preferred payment type. Checks will not be accepted, and IVS does not keep cash on hand to make change.

Signature *

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