Check in form

3195 ROUTE 7A, ARLINGTON, VERMONT 05250

802-375-9491
Please help us make sure we have your most current information.
Name
Primary phone number
Secondary phone number
Address
Email
example@example.com
Pet's Name
Age
Breed
Sex
While our focus today is annual preventive care, tell us what's new with your pet.
Since your pet's last visit do you have any concerns about:

Bad breath Anxiety or behavior Itching, scratching, biting self? Lumps or bumps Urination or defecation habits Coughing or sneezing Pain Weight changes Trouble with getting up steps, running or jumping Other
What dental home care do you provide?

None Dental diet Dental chews Brushing teeth Other
Are you interested in learning more about dental home care?

Yes No
Has your pet had a professional dental cleaning in the past 12 months?

Yes No
Your pet's lifestyle will help us make the best recommendations.
How much time does your pet spend outdoors (hours per day)?

0 1-3 3-6 6-12 12-24
Do you take your pet...

Hiking? Camping? Swimming? Hunting To dog parks? To the groomer? To a boarding facility?
Would you like to discuss the Bordetella and/or canine Influenza vaccines?

Yes No
What food does your pet eat?
Do you give you pet treats and/or table scraps?
How many times a day do you feed your pet?

Once Twice Three times Food is always available Other
Parasitic disease is common in our pets and prevention is key.
Is your pet on a preventative programs for external parasites (Fleas, ticks, mites)

Yes No Unsure
What is the name of the medication?

Bravecto Vectra 3D Seresto Collar Revolution Other
Is your pet on a preventative program for controlling internal parasites (Heartworm, intestinal worms)?

Yes No Unsure
What is the name of the medication?

Interceptor Revolution Other
Are you interested in learning about pet health insurance?

Yes No
Thank you for updating your information!
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