Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. If you are not attending your pet’s appointment with us, please send someone who can make medical and financial decisions for your pet today.Date of Appointment(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet’s Name(Required)Owner’s Name(Required) First Last Does your pet ever go outside?(Required) Yes No What food do you currently feed, including regular treats(Required)How frequently and how much do you feed this pet(Required)What is your pet’s heartworm prevention medication?(Required)When was the most recent dose given?(Required)What is your pet’s flea & tick prevention medication?(Required)When was the most recent dose given ?(Required)Is your pet on any additional medications or supplements on a regular basis?(Required) Yes No Please describe medication/supplement name, frequency of administration, and most recent dose:(Required)Annual Wellness VisitHas your pet been in any social situations (dog parks, daycare, boarding, grooming)?(Required) Yes No Which vaccinations would you like us to administer at your pet’s appointment (select all that apply)?(Required) Rabies Distemper-parvo Bordetella Canine Influenza Lyme Feline Distemper Feline Leukemia Feline Bordetella All that are due Annual bloodwork to monitor your pet's organ function for changes that can affect their quality of life is important. If your pet is due for their annual testing now, do you give permission for our team to collect and send their blood sample to our laboratory?(Required) Yes No Does your pet have any chronic medical conditions such as kidney disease, diabetes, thyroid disease?(Required) Yes No Please explain here(Required)Are there any recent changes in medical condition or behavior that you would like to discuss with the veterinarian at this appointment?(Required) Yes No Please explain here(Required)Do you need refills of chronic medications OR prevention medications during your pet’s appointment?(Required) Yes No Please explain here(Required)Have you noticed any of the following changes since your pet’s most recent examination (select all that apply):(Required) Coughing Gagging Wheezing Vomiting Diarrhea Bad Breath Limping and Lameness Slower to move about Lethargy Itching/Scratching Skin Itching/Scratching Ears New lumps/bumps None of the above Any changes in appetite?(Required) Yes No Explain here:(Required)Difficulty in hearing or vision?(Required) Yes No Would you like any additional services during your pet’s visit today (additional fees will apply)? Nail Trim Anal Glad Expression Owner’s authorization for treatment and care: By signing your name below, you acknowledge that you are financially responsible for all treatment and care provided to your pet during their visit. As well as, acknowledging that you have read and understood this information on this document.(Required)EmailThis field is for validation purposes and should be left unchanged. Δ
