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Preventative Care History

"*" indicates required fields

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.

Name*

First

Last

Email*

Appointment Date/Time*

It is imperative that we be able to reach you in a timely manner while your pet is in the building. Please have your cell phone listed below available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.

Phone*

Pet Information

Pet's Name*

Pet's Age*

Species*

Canine (Dog)

Feline (Cat)

Other

If Other, please explain

Breed*

Microchipping is permanent identification for your pet. Having your pet microchipped is an excellent way to locate your pet should it become lost*

My pet is already microchipped

I’m interested in learning more

I’m not interested in microchipping

Are there any concerns for the doctor to consider this visit?*

How is your pet's appetite?*

Is your pet drinking and urinating normally?*

Is your pet having any sneezing? Coughing? Itching?*

Is your pet having any vomiting or diarrhea?*

Is your pet having any aggression, housebreaking issues, or changes in normal routines?*

We recommend annual fecal testing for intestinal parasites (Intestinal Parasite Exam)*

Brining small sample to appointment

Please send home a prepaid collection container to drop off sample at my convenience

I would like to learn more about regular fecal testing

Other

If Other, please explain

My pet eats*

Wet food only

Dry food only

Wet and Dry Mixture

People Food

Raw Diet

Home Cooked Diet

Other

Choose all that apply

If Other, please explain

Brand of food?*

If prescription diet, what formulation?*

How often is your pet fed?*

How much is your pet fed?*

In addition to pet food, what treats or other food does your pet receive?*

Include any human food, veterinary dental products, bones, rawhides, etc

Has your pet's diet changed in the last 6 months?*

Yes

I am not sure

Do you brush your pet's teeth? How often?*

Current medications / supplements (name, dose, frequency given)*

Any refills needed?*

Additional Information

To help keep healthy, year round heartworm prevention is needed due to the variable nature of mosquito seasons. Mosquitoes can be known to live in your basement/attic and in the sewer system all winter. In addition, heartworm preventatives once monthly help prevent several intestinal parasite infections. We recommend Interceptor Plus once monthly on a year round basis.

Heartworm Prevention refill?*

I want to discuss Heartworm Disease Preventative options with a vet nurse

I have prevention at home

My pet does need to be protected against Heartworm Disease

Other

If Other, please explain

Pets we consider at higher risk of ticks include dogs that go outside. This area has a high incidence of Lyme Disease. Tick-borne diseases such as Lyme Disease are easier to prevent than treat. If your pet has possible exposure, then vaccination for Lyme Disease and applying/giving YEAR ROUND flea/tick preventative is needed. Pets that are in contact with other dogs, such as dog parks or daycare need year round flea/tick prevention.

Flea Prevention refill?*

I want to discuss flea preventative options with a vet nurse

I have prevention at home

My pet does need to be protected against fleas

Other

If Other, please explain

Is there anything else you would like to discuss today?

Appointment Procedures

I understand that payment is due, in full, at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone.*

Please Initial

Signature*

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