Dog Wellness Exam

Wellness Appointment History (Dog)
Date

MonthDayYear
Date
Pet Name*
Owner Name*
Phone Number*
Please enter a valid phone number.
Do you have any concerns you would like addressed today?*
What does your dog eat?
(Food brand and amount eaten; any treats?)
Have you noticed any increase in drinking and/or urinating?

YesNo
Specify:
Is your dog on any medications or supplements?
Any history of medication/injection reactions? Any allergies?
Is your dog on any flea/tick prevention (such as Bravecto, Revolution, etc)?
Has your dog had dewormer in the last year (such as Interceptor)?
If due for flea treatment or dewormer, I would like my dog to receive:
(please specify what form/duration of treatments you would like)
What vaccines would you like given today?

All vaccines that are dueDAP (core dog vaccine)RabiesBordetella/Parainfluenza (kennel cough)Leptospirosis
*Leptospirosis vaccine has been recommended by the Canadian Vet Med Association to be part of the core vaccine schedule for dogs. This is a disease that dogs can get from drinking out of puddles/streams and is a disease that can spread to humans. If not had previously, this vaccine will need a booster given at a recheck appointment in 4 weeks, and then will be due annually.
Any other information that you would like the NIVH team to know?
If you have any history or photos you would like to share, please attach here:

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Wellness Appointment History (Dog)