Canine Wellness Form
Please answer all of the questions to the best of your ability.
Client Name
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First Name
Last Name
Preferred Form of Contact
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Phone
Email
Best Phone Number / Email Address
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Dog Name
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Does your dog/puppy have any medical conditions or had any surgeries?
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Is your dog/puppy allergic to any medications? Has he/she had any reactions to any vaccines given previously?
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Is your dog/puppy on any medications, vitamins, or supplements daily? (Please list Medication name, strength (MG), how much he/she is getting, and when the last time he/she received it)
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Is your dog/puppy on any flea/tick or heartworm preventatives? What brand?
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Do you need any refills of your flea/tick medication or any medications listed above? (please list how many refills you would like)
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Is your dog/puppy ok if we pick them up, touch their face, paws, ears, or tail? Is there anything they do not want us to touch?
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What diet is your dog/puppy currently eating? How much and how often?
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Is your puppy/dog on a grain-free diet?
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Yes
No
Do you have a pet insurance plan for your dog/puppy?
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Has he/she been microchipped? If not, would you like a microchip?
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Do you have a Regular Veterinarian you use? Is it ok if we call for previous records or will you be bringing them to your visit?
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What age is your dog?
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0-11 Months Old
1 - 4 Years Old
5 - 8 Years Old
9+ Years Old
Are there any other pets in your household?
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Yes
No
Does your dog/puppy visit any dog parks, groomers, day care, etc.?
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Yes
No
Our veterinarian would suggest the following vaccines and bloodwork for a dog 0-11 Months Old. Which of the following would you like to receive today?
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Bordetella Vaccine - $33
DHPP (Distemper, Parvo Virus, Parainfluenza) Vaccine - $33
Rabies Vaccine - $33
Canine Influenza Vaccine - $33
Lyme Vaccine - $33
Leptospirosis Vaccine - $33
Fecal and Heartworm Test - $85
Nail Trim with Exam - $11
Flea and Tick Prevention (Bravecto) - $57.75 per 3-Month Dose. Ask about our bundles which can save you up to $75!
Heartworm Preventative (Sentinel Spectrum) - Price varies depending on weight. Ask about our bundles which can save you up to $75!
Other
Our veterinarian would suggest the following vaccines and bloodwork for a dog 1-4 Years Old. Which of the following would you like to receive today?
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Bordetella Vaccine - $33
DHPP (Distemper, Parvo Virus, Parainfluenza) Vaccine - $33
Rabies Vaccine - $33
Canine Influenza Vaccine - $33
Lyme Vaccine - $33
Leptospirosis Vaccine - $33
Fecal and Heartworm Test - $85
Young Annual Wellness Bloodwork Panel (recommended for ages 1-4) - $144
Nail Trim with Exam - $11
Flea and Tick Prevention (Bravecto) - $57.75 per 3-Month Dose. Ask about our bundles which can save you up to $75!
Heartworm Preventative (Sentinel Spectrum) - Price varies depending on weight. Ask about our bundles which can save you up to $75!
Other
Our veterinarian would suggest the following vaccines and bloodwork for a dog 5-8 Years Old. Which of the following would you like to receive today?
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Bordetella Vaccine - $33
DHPP (Distemper, Parvo Virus, Parainfluenza) Vaccine - $33
Rabies Vaccine - $33
Canine Influenza Vaccine - $33
Lyme Vaccine - $33
Leptospirosis Vaccine - $33
Fecal and Heartworm Test - $85
Intermediate Annual Wellness Bloodwork Panel (recommended for ages 4-8) - $245
Nail Trim with Exam - $11
Flea and Tick Prevention (Bravecto) - $57.75 per 3-Month Dose. Ask about our bundles which can save you up to $75!
Heartworm Preventative (Sentinel Spectrum) - Price varies depending on weight. Ask about our bundles which can save you up to $75!
Other
Our veterinarian would suggest the following vaccines and bloodwork for a dog 9+ Years Old. Which of the following would you like to receive today?
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Bordetella Vaccine - $33
DHPP (Distemper, Parvo Virus, Parainfluenza) Vaccine - $33
Rabies Vaccine - $33
Canine Influenza Vaccine - $33
Lyme Vaccine - $33
Leptospirosis Vaccine - $33
Fecal and Heartworm Test - $85
Senior Annual Wellness Bloodwork Panel (recommended for ages 8+) - $263
Nail Trim with Exam - $11
Flea and Tick Prevention (Bravecto) - $57.75 per 3-Month Dose. Ask about our bundles which can save you up to $75!
Heartworm Preventative (Sentinel Spectrum) - Price varies depending on weight. Ask about our bundles which can save you up to $75!
Other
Is there anything you would like to discuss with the doctor at this appointment?
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Submit
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