Intake Information for Wellness Exam - Dog
Kirkland
Name
*
First Name
Last Name
E-mail
*
Phone Number
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Area Code
Phone Number
Date of Upcoming Appointment
*
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Month
-
Day
Year
Date
1
2
3
4
5
6
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8
9
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11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Pet Details
Pet's Name
*
Feeding
What do you feed your dog? Please select all that apply
Dry Food
Canned Food
Treats
Other
DRY FOOD
Dry Food Manufacturer
Name of Dry Food
Please indicate if this is a grain-free food
Quantity of dry food fed per meal?
e.g. 1/2 cup
Number of dry food meals a day?
CANNED FOOD
Canned Food Manufacturer
Name of Canned Food
Please indicate if this is a grain-free food
Quantity of canned food fed per meal?
e.g. 1/2 can
Number of canned fed meals a day?
Treats
Please enter names and quantities of treats per day
e.g. 1 tsp peanut butter, 2 times a day.
Other Food
Food Manufacturer
Name of Food
Please indicate if food is grain-free
Quantity of food given per meal
e.g. 2 cups
Number of feedings a day?
Treats During Exam
Are we allowed to give your pets treats during exam?
Yes
No
Please select treats (select all that can be given)
Freeze Dried Beef Liver
Chicken
Peanut Butter
Cheese
Hot Dog
Please tell us why not.
General Health
Where does your dog go? (select all that apply)
Dog Parks
Kennel
Grooming
Daycare
Hiking or locations where there are more ticks
Does your dog exhibit any of these symptoms at least once a week? (select all that apply)
Coughing
Sneezing
Vomiting
Diarrhea
Increased urination
Increased drinking
Please tell us more about the symptoms
Please indicate length of time symptoms have been observed, and frequency of symptom.
Medications
Do you give your pet any medications?
Yes
No
What medication do you give your pet? Please select all that apply.
Trifexis
Sentinel
Bravecto
Credelio
Proin
Rimadyl
Glucosamine
Other
Please tell us more about the medication
Please indicate how you are dosing the medication (s) and last dose administered.
Concerns
What is the reason for your visit? Please indicate any concerns do you have about your pet that you want to discuss with the doctor.
*
If listing a problem, please include length of time problem has been observed.
Photo(s)
Upload a recent picture of your pet, and any pictures of areas of concern.
Browse Files
You may select file(s) or drag and drop file(s) onto the 'Browse File' button.
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