Patient Risk Assessment/Client Update Form
Client Information
Owner's Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
*
Please Select
Home
Cell
Work
Alternative Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
Please Select
Home
Cell
Work
Alternative Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
Please Select
Home
Cell
Work
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preference for contact
*
Phone
Email
Other
We love social media! Do we have your permission to share your pet’s image and story on our social media and/or website? Your name and personal information will never be shared; we only use your pet’s first name.
*
Yes
No
Pet Information
Pet's Name
Pet's Age
Species
Dog
Cat
Other
Is Your Pet
Spayed
Neutered
Declawed (cat)
Other pets in household: (Dog, Cat, Age)
Who is the Medical Insurance provider for your pet?
Trupanion
Nationwide
Pets Best
Embrace
Pet Care
AKC
ASPCA
Other
Please Explain
What does your pet eat? (include brand names, amount and frequency; include snacks and treats)
Is your pet on heartworm prevention?
Yes
No
Where do you purchase your heartworm preventive?
OSSVH
Pet Store
Big Box Store (Costco, Walmart, etc.
Online
Other
Have you missed any doses of heartworm preventive?
Yes
No
Is your pet on flea and tick preventive?
Yes
No
Where do you purchase your flea and tick preventive?
OSSVH
Pet Store
Big Box Store (Costco, Walmart, etc.)
Online
Other
Is your pet on any other medications (including vitamins and nutritional supplements)?
Yes
No
List types, doses, and frequency of medications and supplements
Dental Health
Brushing teeth daily
Brushing teeth weekly
Brushing teeth monthly or less
Supplement
Water additive
Dental diet
Other
Where does your pet sleep?
In bed with owner
In crate
In their own bed
Anywhere they want
Other
How much time is your pet spending outside?
Never
Just to potty
Out in fenced yard
Pet door
Invisible fence
Leash walks
Roams free
How does your pet travel in car?
No restraint
In lap
Carrier or crate
Seat belt
Barrier
Travel plans for your pet?
Has not been outside of Maryland
Frequent trips outside the state
No travel plans
Do you have boarding plans for your pet?
Yes
No
If Yes, When And Where?
Does your pet go to
Groomer
Dog / Cat
Dog Park
What does your pet do for fun?
What are your concerns today?
Check any that apply
Difficulty rising, walking, jumping, climbing stairs
Change in urinations or water consumption
Accidents in the house OR litterbox problems
Weight gain or loss
Change in appetite
Change in activity level
Change in behavior
Difficulty seeing or hearing
Difficulty eating or chewing
Scratching/licking or chewing
New lumps, bumps or skin problems
Hair loss
Small children or immune compromised people in household
Evidence of fleas or ticks
Vomiting or diarrhea
Coughing or sneezing
Known allergies
Known reactions to vaccines or medications
Explain
Submit
Should be Empty: