Wellness Exam Questionnaire

Today's Date*

Date

Your Name:*

First NameLast 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?*

YESNO

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

Is your pet current on heartworm prevention?*

YESNO

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?*

YESNO

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?*

NOYES

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 Exam services are for well pets only and only include a brief exam. If I am concerned about any health issues (allergies, skin/ear issues, digestive disturbance, etc.), I will be directed to schedule a regular appointment with IVS, and/or your 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 the appointment date. IVS does not recommend vaccines be administered if these issues are occurring due to possible health risks. I understand that IVS recommends checking for parasites prior to any vaccination. I also understand that IVS does not recommend giving multiple vaccinations at once, and instead recommends waiting at least 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 rabies vaccination.

MEDICATIONS: I am aware that IVS utilizes an online pharmacy (VetSource) 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 (Visa, MC, Discover, & AMEX) are the accepted payment types. Checks will not be accepted, and IVS does not accept, nor keep cash on hand.

Signature*

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