Returning Client Information
Please make sure we have your current contact information
Name
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Cell Phone
E-mail
example@example.com
May we text you with lab results?
Yes
No
What is your preferred method of contact?
Call
Text
Email
Spouse/Co-Owner Name
First Name
Last Name
Contact Number
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Pet Information
While our focus today is annual preventive care please tell us if anything is new or has changed with your pet
Pet's name
First Name
Last Name
Since your pet's last visit do you have any behavior or health concerns about any of the following (select all that apply)
Appetite or water intake
Coughing or sneezing
Lumps or bumps
Digging or clawing damage
Weight changes
Urination or defecation habits
Itching, scratching or biting self
Excessive barking
Limping, trouble with getting up, steps, running or jumping
Anxiety or behavior changes
Vomiting or diarrhea
Bad breath
Biting or scratching people
No concerns today
What dental home care do you provide your pet?
Brush teeth
Dental chews or treats
Dental diet
Water additives
If any dental home care, how many days a week do you provide these?
1
2
3
4
5
6
7
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Pet Lifestyle
How many hours a day does your pet spend outdoors?
0
1-3
3-6
6-12
12-24
Does your pet do any of the following activities?
Hunting
Swimming
Hiking
Camping
Does your pet go to any of the following places?
Boarding/kennel facility
Grooming facility
Dog park
Dog daycare/camp
Do you take your pet on vacation? If yes, where?
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Parasite Prevention
What heartworm prevention is your pet on?
Proheart 12
Proheart 6
Interceptor Plus
Heartgard
Not sure/other
None
What flea and tick prevention is your pet on?
Bravecto
Credelio
Nexgard
Frontline Plus
Revolution
Flea Collar
Not sure/other
None
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Diet
What food are you currently feeding your pet?
How many times a day do you feed your pet?
Once a day
Twice a day
Three times a day
Free feed
Food is always available
Does your pet receive any treats or table food? If yes, what?
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Do you currently have health insurance for your pet?
Yes
No
Are you interested in learning more about pet health insurance?
Yes
No
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