Veterinary Assessment Form
Veterinary Report No.
Owners Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owners Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Animal Information:
Animal Name
Sex
Dog
Bitch
Breed
Age
Color/Markings
Microchip or ID Number:
Health Assessment:
Weight
lbs/kg
Body Condition Score
Underweight
Ideal
Overweight
Vaccination Status
Up-to-date
Not up-to-date
Unknown
Kennel Cough Up-to-date (our minimum requirement)
General Medical History - Areas of Concern
Any known medical conditions, treatments, or medications
Physical Examination:
General Appearance
Alert and responsive
Lethargic
Aggressive
Other
Coat and Skin
Normal
Abnormal
Eyes
Clear and bright
Redness or discharge
Ears
Clean
Waxy buildup
Mouth and Teeth
Healthy gums and teeth
Dental issues
Heart Rate
beats per minute
Respiratory Rate
breaths per minute
Temperature
degrees Fahrenheit/Celsius
Additional Comments
Veterinarian Comments or Recommendations (non-referrals)
Findings, recommendations, or additional notes
Is this animal fit for active walking - OR- vet referrals?
Yes - this animal is deemed healthy to the best of our ability
YES - Provided reduced speed by the operator using a speed regulator (normal speed performed by the canine as machines are not powered)
Vet Referrals - Please provide your detailed requirements we will liaise with you directly subject to prior agreements with the animal owners
NO - This animal is NOT fit and should not use any form of enhanced exercise equipment
Vet Referral information
Veterinary Signature & Practice Stamp
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Practice Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
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