Preventive Care Survey for Dogs
Pre-visit survey for preventative care
Dog’s Name
*
Your Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is your dog microchipped?
*
Yes
No
Unsure
Please tell us about your dog’s diet
*
Please tell us about any treats, dental chews, and human food your dog receives.
Your dog’s body condition is
Overweight
Ideal
Underweight
Unsure
Which Heartworm prevention is your dog receiving?
*
Interceptor Plus
Heartgard Plus
Proheart6
None
Other
When was your dog’s last dose given?
*
Which flea & tick prevention is your dog receiving
*
Bravecto
Nexgard
Credelio
None
When was your dog’s last dose given?
*
Please tell us about any other prescription, OTC medications, &/or supplements your pet is taking, including current dose and frequency.
Please check any of the following that apply:
*
My dog lives with other animals
My dog lives with children
My dog visits dog parks
My dog goes to grooming/boarding facilities
If your dog is having any mobility or comfort issues, please describe them here.
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Submit
Should be Empty: