Preventive Care Survey for puppies
Puppy’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 puppy microchipped?
Yes
No
Unsure
Please tell us about your puppy’s diet
*
Please tell us about any treats, dental chews, and human food your puppy receives.
What is your puppy’s date of birth?
-
Month
-
Day
Year
Date
If birthday is unknown, please give approximate age.
When and where was your puppy acquired?
Has your puppy started heartworm/intestinal worm prevention?
*
Interceptor Plus
Heartgard Plus
Proheart6
None
Other
When was your puppy’s last dose given?
*
Has your puppy started flea & tick prevention?
*
Bravecto
Nexgard
Credelio
None
Other
When was your puppy’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 puppy lives with other animals
My puppy lives with children
My puppy visits dog parks
My puppy goes to grooming/boarding facilities
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Submit
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