Free Parasite Control Dose Information
Basic Information
Since we will be administering a prescription medication to your pet, there is certain information we legally have to collect. We PROMISE that we will not enter this data into our systems or use it in any way unless and until you actually come to Animal Care Clinic and access our services.
Human's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Pet's Name
Species
Dog
Cat
Breed
Age or birthdate
Color
Gender
Female
Female spayed
Male
Male Neutered
Basic Medical History
We need to ask a few questions about your pet's health so we can ensure our parasite control products will be safe to administer:
Has your pet experienced any of the following in the past 30 days? (check all that apply)
poor energy
poor appetite
vomiting
diarrhea
coughing
sneezing
prolonged increase in thirst
prolonged increase in urination
None of the above
Has your pet experienced any of the following ever? (check all that apply)
Seizures
Autoimmune Disease
Vaccine or Drug reaction
Cancer
None of the Above
Has your pet received any vaccines or parasite control in the past 90 days? If so, what products and approximately when?
Please list all medications and supplements your pet is taking
Next Steps:
Thank you for taking the time to complete this form. Once you submit it, we will hang on to it for 30 days. If you decide to come visit us and get your free dose of parasite control, bring your pet with you any time between 8am & 5pm M, T, Th, F or 11am to 5pm on Wednesdays. NOTE THAT YOU MUST BRING YOUR PET AS WE CANNOT SEND THE MEDICATION HOME WITH YOU. We can't wait to meet you!
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