Annual Wellness Form
Please complete this form at least an hour prior to your appointment with us. This will allow us to review the information before you arrive at the clinic, and let our medical staff determine if there are any other questions we need to ask. If you have any questions or concerns, please call us at 918-481-1693. THIS FORM IS REQUIRED FOR US TO BEGIN YOUR APPOINTMENT
What is your name (Please include first and last name)? *
What is your pet's name? *
What date is your appointment?
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What is the best phone number to reach you at during your appointment, so we can call you to discuss the exam findings? THIS IS THE NUMBER WE WILL CALL TO DISCUSS EXAMS AND CHARGES. PLEASE LIST THE NUMBER YOU WOULD LIKE FOR US TO CALL TO GO OVER THE EXAM AND COLLECT PAYMENT. (If you would please format the phone number as xxx-xxx-xxxx, we would appreciate it!) *
What is the best email address to send you any instructions the Veterinarian has for you? *
You have scheduled your pet for an Annual Wellness Appointment. Our Annual Wellness appointments include a full examination, all vaccines that are currently due, a heartworm test and a fecal screening for intestinal parasites. Would you like for us to perform a full Annual Wellness? If no, we will perform the examination and call you prior to administering any vaccines. *
Are there any concerns you have with your pet that you would like the veterinarian to take a look at? *
How much time does your pet spend outside on a daily basis? *
Has your pet come into contact with any other animals in the last 2 weeks? (boarding, dog park, grooming, out on walks, through the fence, etc) *
Is your pet on any medications, prescribed or over the counter? IF YES PLEASE LIST MEDICATIONS, STRENGTH, AND FREQUENCY THAT YOU ADMINISTER MEDICATIONS. *
Is your pet current on heartworm prevention? IF YES WHAT BRAND ARE YOU USING AND WHEN DID YOU GIVE THE LAST DOSE? *
Is your pet current on flea and tick prevention? IF YES WHAT BRAND ARE YOU USING AND WHEN DID YOU GIVE THE LAST DOSE? *
What food are you feeding your pet? PLEASE LIST BRAND, AMOUNT, AND FREQUENCY IN WHICH YOU FEED. *
Has there been any change in your pet's diet in the last 7 days? (Change in food, table scraps, gotten into the trash, etc) *
Has there been any change to your pet's attitude? IF YES PLEASE DESCRIBE. *
Has there been any change to your pet's food intake or water intake? IF YES PLEASE DESCRIBE.
Where was your pet last vaccinated? *
If your pet has been having any diarrhea or vomiting, please describe and how often has it been happening? *
Is there any discharge or drainage from the nose or eyes? Please describe. *
Has there been any coughing or sneezing recently? *
Have you noticed your pet scratching or chewing? If so, what area(s) is/are the main focus? *
If we cannot reach you, we will NOT perform any testing or treatment beyond the medical exam. Please type your initials below to state you understand. *
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