Drop off Appointment Questionnaire

Your Name (required)
Your Email (required)
Phone Number 1 (required)
Phone Number 2
Pet's Name (required)
Reason for visit ($50.95 exam fee) Wellness ExamIllnessInjuryOther
Please check all that apply to your pet:
Not EatingDecrease in AppetiteIncrease in AppetiteNot DrinkingIncreased ThirstWeight LossWeight GainVomitingDiarrheaSkin Masses/LumpsScootingShaking HeadUrination IssuesLimping/LamenessStiffnessBad BreathDroolingChewing or LickingScratchingHair LossCoughing/SneezingGaggingSquinting EyesLacerationsOpen WoundsLethargicChange in Activity LevelExcessive PantingLabored BreathingOther

If you checked any of the above, please list the duration of the symptoms that are present

Are there any other concerns not listed above? If yes, please explain

Please check any preventative care services that you would like for your pet to receive
Test for Heartworm and Lyme/Tick Borne Disease - Dogs only ($41.00)Intestinal Parasite Screening ($21.00)Implant Home Again Microchip for Identification? ($41.55 - includes first year registration fee)Anal Glad Expression ($20.80)Clean Ears ($15.30)To Nail Trim (no charge)Other

Please Dispense
Topical Heartworm, Flea and Tick Medication for Cats - Revolution PlusTopical Flea Only Medication for Cats - VectraFlea and Tick Medication For Dogs - Topical Vectra 3DFlea and Tick Medication For Dogs - Oral SimparicaOral Heartworm Prevention for Dogs - SentinelGive Injectable ProHeart 6Give Injectable ProHeart 12

Please check any vaccines that you would like your pet to receive today
Cat FVRCP ($20.25)FELV ($34.00)RABIES ($26.75)
Dog DAPP ($20.25)LEPTO ($20.25)RABIES ($26.75)LYME ($37.00)BORDATELLA ($26.75)CANINE INFLUENZA ($39.00)
*The Bordetella and Canine Influenza vaccines are usually required by most kennels and groomers.

Is your pet taking any medications?YesNo

Please list medications

Any refills needed?

Has your pet had any adverse reaction to any medication or vaccines in the past?YesNo

If so, please describe

What food do your feed your pet?

Do you feed your pet treats?
YesNo

If yes, what kind?

Additional Information