Medical, Dental and Requirements
Date
-
Month
-
Day
Year
Dog's Name
Comprehensive Medical Exam
Complete
Fully Healed from any Medical Treatments
Yes
No
Note Any Abnormal Findings
Comprehensive Dental Exam
Complete
Prophylactic Treatment
Complete
Note Any Abnormal Findings
Spayed or Neutered
Complete
Attach Spay/Neuter Certificate if Available
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Tests
CBC (Complete Blood Count)
Complete
Attach Results of CBC
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Chemistry Panel
Complete
Attach Results of Chemistry Panel
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Snap4Dx (Anaplasma, Lyme Disease, Heartworm, Ehrlichia)
Complete
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Urinalysis and Urine Specific Gravity
Complete
Attach Results of Urinalysis and Urine Specific Gravity Attach
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Fecal Antigen for Parasites
Complete
Attach Results of Fecal Antigen for Parasites
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TVT Cytological Examination
Complete
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Medications
Deworming(Dates and Product used) Repeat per label directions for animals testing positive)
Complete
Deworming (Dates and Product used) Repeat per label directions for animals testing positive.)
Flea, Tick, Heartworm Preventative
Complete
Flea, Tick and Heartworm Preventative (Date and Product used)
Vaccinations
Bordetella
Complete
Attach Label from Vial Administered
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Rabies Vaccine
Complete
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Multivalent Vaccine(Merial or Virbac) Distemper, Leptospirosis, Parvovirus, Adenovirus Type 1 and2, Parainfluenza Attach label from vial administered
Complete
Attach Multivalent Label from Vial Administered
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Other
Teeth Cleaning
Complete
Nails Clipped
Complete
Ears Cleaned
Complete
Bathed
Complete
Submit
Should be Empty: