Canine (Dog) Pre-Exam History Form

1
Owner/Responsible Person* This field is required.
First Name
Last Name
2
Patient Name* This field is required.
3
Best Contact Number* This field is required.
4
How would you like to be contacted?* This field is required.
Text
Phone Call
5
Has your pet ever had ANY adverse (allergic) reaction to any medications, vaccinations, or other procedure?* This field is required.
YESNO
6
Please check the following services you would like updated with today's Annual Wellness appointment.* This field is required.All Annual Wellness Visits require a Comprehensive Annual Wellness Exam. (Please check all that apply)
Distemper-Parvo +/- Lepto Vaccine
Rabies Vaccine
Kennel Cough/Bordetella Vaccine
Heartworm Test
Fecal/Intestinal Parasite Screen
Annual Wellness Bloodwork
Rattlesnake Vaccine
Canine Influenza Vaccine
I am unsure and would like to discuss recommendations with a staff member
7
Additional Services* This field is required.Additional cost will apply (Please check all that apply)
Nail Trim
Laser Therapy
Nail Trim w/Dremel
Cytopoint
Ear Cleaning
Librela
Sanitary Trim
Toothbrushing
None
Other
8
Lab work results can take up to 48 hours to receive. Histopath or Cultures can take up to 14 days to receive. How would you like to be contacted once we receive your pet's results?* This field is required.
Text
Phone Call
9
Have you noticed any of the following problems/concerns with your pet:* This field is required.(Please check all that apply)
Increase in appetite
Itching/Scratching
Decrease in appetite
Increase in drinking
Shaking Head
Decrease in drinking
Bad Breath
Weight Loss
Vomiting/Gagging
Weight Gain
Diarrhea
Increase in Urination
Difficulty Standing
Decrease in Urination
Excessing Sleeping
Scooting
Skin Masses/Bumps
Behavioral Problems
Coughing
Sneezing
No Concerns
Other
10
Is your pet on any prescription medications or over the counter medications/supplements?* This field is required.
Yes
No
11
If yes, please list all medications/supplements, including doseage and how often
12
What brand of food do you feed your pet?* This field is required.
13
How much do you feed your pet?* This field is required.
Free Fed (food is offered always/whenever hungry)
Measured amount
14
If measured, please specify how much and how often below
15
Do you give your pet heartworm and flea/tick prevention regularly?* This field is required.
Yes (Both)
Yes, and I would like a refill today
Yes (Heartworm Preventative only)
Yes (Flea/Tick Preventative only)
Sometimes
No
16
If yes, please specify what brand of prevention you give your pet.
17
Do you have other pets?
YESNO
18
Does your pet come into contact with other dogs? Please check all that apply* This field is required.
No
Boarding
Grooming
Dog Parks
Pet Stores
Other
19
Do you have any additional questions/concerns that you would like to discuss at your appointment?
Huge
Large
Normal
Small
Ok
Ok
20
Social Media/Photo Permission Do we have your permission to post photos/videos of your pet online?* This field is required.
YESNO
21
Payment Authorization: I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time of service unless prior arrangements have been made. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, interest, attorney fees, court costs and collection agency fees. I hereby authorize Monroe Veterinary Clinic to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible and authorize treatment necessary should any reaction occur.* This field is required.
I agree
I disagree
22
Signature* This field is required.
Print Full Name
23
Date* This field is required.
Date
Month
Day
Year
Should be Empty: