Canine Medical Intake
Your Name
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First Name
Last Name
Pet's Name
*
Best Number to reach you at
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Number
Please enter a valid phone number.
Format: (000) 000-0000.
My pet is here for....
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Vaccines/Annual Exam
Recommended Recheck
Sickness/Illness
Vaccines/ Lab work approved
Rabies
Distemper/Adnovirus/Parvo
Bordetella
Lepto
Lyme
Canine Influenza
Junior wellness panel
Senior wellness panel
I wish to discuss wellness panel with the doctor first
What are we rechecking?
Please check all that apply
Lethargy
Diarrhea
Vomiting
Coughing
Urination issue
Loss of appetite
Increased thirst
Sneezing
Ear irritation
General itching
Growth
Not acting right
Limping
Eye
Other
Limping on which leg(s)
Which eye?
Where are the growth(s) located?
How long has the problem been going on? Include any other information you fees is useful
What monthly heartworm/flea/tick prevention is your pet on?
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SimparicaTRIO (three in one)
Simparica (heartworm only)
Heartgard Plus
Nexgard
Nexgard Plus (three in one)
Trifexis
Frontline
Revolution
No Heartworm prevention given
No Flea and tick prevention given
Other
Is your pet on any other medication?
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Yes
No
Please list the medications and frequency given
Is your pet on any supplements?
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Yes
No
Please list the supplements and frequency given
What is your pets main diet
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Does your pet get any human food?
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Yes
No
What do they typically get?
Does your pet get any treats?
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Yes
No
What kind of treats and how often?
Where does your pet spend MOST of their time
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Please Select
Indoors
Outside
Equal times inside and out
Does your dog visit any of the following:
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Dog Park
Daycare
Boarding
Groomer
Other states
What other states
Are there any other pets in household? If yes please list what kinds
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Do you need an estimate for today?
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Yes
No
Other
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