"*" indicates required fields

Pet's Name *

Client Name *

First

Last

Phone *

Email *

Do you have time constraints? *

Does your pet have insurance?

Yes
No

For today's visit the following symptoms are present:

Diet: (what brand of food and amount fed per day. i.e. 2 cups twice daily, 1/4 can three times daily)* *

Any change in food/treats? *

Yes
No

Current medications/supplements and dose given: *

Monthly heartworm / deworming / flea preventive

Appetite *

Normal
Decreased
Increased

Water Intake *

Normal
Decreased
Increased

Activity Level *

Normal
Abnormal

Food Allergies? *

Other Allergies? *

Any seizures? *

Percentage of time spent indoors *

History

How is your pet doing at home? *

Clear Signature

Have you noticed any changes to their normal behavior? *

Yes
No

What concerns that you would like to address today?

Do you need any medication refills? *

Yes
No

Vaccine Lifestyle Information and Consent

Do you take your pet hunting/hiking/camping/swimming, or playing in/near rivers ? *

Yes
No

Does your pet have exposure to standing water puddles, parks, water features, etc? *

Yes
No

Is there a possibility of sniffing the ground where rats or wildlife have been? *

Yes
No

Does your dog go to day-care/boarding/grooming/dog parks? *

Yes
No

Does your dog have exposure to ticks (wooded areas)? *

Yes
No

Vaccine Lifestyle Information and Consent

DHPP (distemper/parvo vaccine) *

Accept
Decline

Leptospira (transmitted in urine of animals - contagious to people) *

Accept
Decline

DHLPP (if receiving both the DHPP and Lepto) *

Accept
Decline

Rabies *

Accept
Decline

Bordetella (for kennel cough) *

Accept
Decline

Influenza (canine flu vaccine - recommended with exposure to other dogs such as dog parks, grooming, day care, and boarding *

Accept
Decline

Vaccine Titer (can be done in place of DHPP) *

Accept
Decline

Signature *

Clear Signature

Date *

CANINE ANNUAL EXAM HISTORY

Fill Out the Form

History

Vaccine Lifestyle Information and Consent

Vaccine Lifestyle Information and Consent

Hospital Hours

Hospital Policies