RRVH- Wellness Visit

Wellness Exam Form

Your pet is scheduled for a wellness examination. We recommend these examinations every 6 months for pets. Answering a few questions ahead of time will help us use our time with your pet more efficiently and hopefully reduce your time waiting.
Your name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email *
example@example.com
Your pet's name*
What concerns do you have about your pet's health?*
Have there been changes in your pet's:*

AppetiteThirstStoolsUrinationNo changes to any of the above
Have you noticed any recent:*

CoughVomitingDischarge - Eyes, NoseScratchingNo changes to any of the above
If you've selected "scratching" in the question above, please specify where:
Specify location of scratching
What medications AND supplements do you give?*
What diet do you feed? How much, how often?*
Part of the wellness exam involves laboratory tests:

The CDC recommends regular fecal parasite testing. Please bring a sample.

Dogs need an annual blood test for heartworm. If it is due, we will start this test right away.
Pet's on long-term medications generally require lab testing of some type every 6 months. If this is due, may we submit this today?*

YesNo
Your pet may be due for vaccines. We will discuss vaccines or any other treatment with you before administering anything.
Will you need any heartworm or flea and tick preventives today?*

YesNo
Would you like an estimate of cost for the services today?*

YesNo
Should be Empty:

Wellness Exam Form