Client's Name *

First

Last

Email *

Pet Name *

Date *

As a reminder we are allowing 1 pet parent into the exam room or you may choose to have a curbside appointment.

Who will be bringing your pet to the appointment? *

Me
Other

Name *

First

Last

If this person is not the owner, please indicate their relationship to you and if they are able to make medical and financial decisions on your behalf. *

Person is the owner
Person is not the owner

Relationship to you: *

Is this person authorized to make medical and financial decisions on your behalf? *

Yes
No

Please answer the following questions

Species *

Dog
Cat

Is your pet eating & drinking ok? *

Yes
No

Please explain: *

What kind of food are you feeding? *

How often does your pet eat? *

1x Daily
2x Daily
3x Daily
Free Feeding

Does your pet get human food? *

Yes
No

Is your pet currently taking any medication (including prevention)? *

Yes
No

List medication & last dose given: *

Do you need any medication refills today? *

Yes
No

Has your pet ever had an adverse reaction to a vaccine or medication? *

Yes
No

What medication & when? *

Does your pet go to daycare, boarding, dog parks, or grooming? *

Yes
No

How often? *

Does your pet go outside? *

Yes
No

If yes, does s/he hunt (catch mice, rabbits, bird, etc)? *

If your pet goes outside is s/he kept in a confined area such as a screen porch/fenced in yard? *

Yes
No

Does your pet come into contact with any other animals (such as family/friend pets)? *

Yes
No

Does your pet have thunderstorm anxiety? *

Yes
No

Has your pet been involved and/or injured in any fights (cats, raccoons, etc) within the past 2 years? *

Yes
No

Does your pet have anxiety? *

Yes
No
Not sure

If yes, has there been any recent changes/stresses in the house? *

Is your pet interacting less often with the family? *

Yes
No

Is your pet responding less often or less enthusiastically? *

Yes
No

Do you have any specific questions for the doctor today?

Are there any concerns for: (Check all that apply) *

Other: *

Please check off any vaccines / tests / services that you would like performed: *

Other *

Bloodwork

Would you like to perform annual bloodwork on your pet today?

Yes
No

Beginning at the age of 6 years, we recommend a yearly blood panel to get an idea of your pets metabolic and organ health.

Select blood work: *

Full Chem/CBC/Lytes - $145: Full blood work an all major organs, full red and white blood cell count, and electrolytes.
Partial Chem/CBC/Lytes - $125: Basic internal organ screen (liver, kidneys) with full red and white blood cell count, and electrolytes.
I decline blood work.

Thank you for your help in answering these important questions! As a reminder, payment is due when services are rendered. If you need an estimate for your appointment please call us and we can email you one.

Signature

Clear Signature

Date *

Annual Exam Questionnaire

Please answer the following questions

Bloodwork