Potomac Animal Wellness Services
4618 Indian Head Hwy Indian Head, MD 20640 Phone Number:301-743-5411
Patient Drop Off History Form
Your Pet's Name
We will need to be able to contact you or someone with permission to make medical and financial decisions. Who will we be speaking with?
1st choice phone number
2nd choice phone number
Reason for visit:
Vaccines: Check all that you would like done
(*required for boarding)
Additional testing/ diagnostics
Heartworm/ Lyme/ Ehrlichia/Anaplasma test(dogs only)
Feline Leukemia/FIV/Feline Heartworm (cats only)
Other services: Are there any other services that you would like done while your pet is here today?
Anal Gland Expression
Pet's Medical History
What diet is your pet eating?
When did your pet last eat?
Has your pet ever had an adverse reaction to any medications?
Has your pet ever had an adverse reaction to any vaccines or any procedure? If yes, please describe.
What heartworm preventative is your pet on?
What flea/tick preventative is your pet on?
Do you need a refill on any of your preventative medications?
Please list any medications that your pet is taking.
Name of medication
When last dose was given
Have you noticed any changes or do you have any concerns about any of the following in your pet?
Are there any other concerns that you may have that are not listed above?
Please describe what you have been seeing, include how long you have noticed the concern and how it has progressed over time. How frequently is it happening?
Is this the first time you've noticed this issue?
Have you tried any treatment? Did it help?
Should be Empty: