Canine Annual Wellness- Day Admission Form – East Dallas Veterinary Clinic

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Canine Annual Wellness- Day Admission Form

We have arranged for you to leave your pet here, to allow examination of your pet as soon as possible today. Please read through the following questions, and answer any that may apply to your pet today.

Owner's Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone #*
Secondary Phone
Email*
Enter Email Confirm Email
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Sex
Services requested:
Please provide a list of any concerns:
What heartworm and flea/tick preventative are you using?
Do you need a refill?
- 1 dose
- 6 doses
- 12 doses
What brand of food do you feed your dog?
Do you provide dental care for your dog?
- Yes
- No
If no, are you interested in providing dental care?
- Yes
- No
General Health Questions Regarding Your Pet
Has your pet had any: ( check all that apply)
- Vomiting
- Diarrhea
- Limping
- Soreness
- Coughing
- Sneezing
- Lethargy
- Growths
Has your pet had a change in water consumption?
- Increase
- Decrease
- No change
Has your pet had a change in food consumption?
- Increase
- Decrease
- No change
Has your pet had a change in urination?
- Increase
- Decrease
- No change
If intact, last heat cycle?
Any chance your pet is pregnant?
- Yes
- No
Is your pet on any medications? If yes, please list:
We recommend annual blood work to screen for internal organ function, infections, and anemia - all items that can not be detected on physical examination alone. Would you like to have a blood test performed on your pet (additional fee)
- Yes
- No
General Questions To Help Us Choose The Best Vaccination Protocol For Your Pet:
Has your pet ever had a vaccination reaction?
- Yes
- No
Does your pet go to boarding or grooming?
- Yes
- No
Does your pet go to heavily wooded areas, lakes, or farms with cattle?
- Yes
- No
Does your pet go hunting?
- Yes
- No
Do you have any problems with ticks?
- Yes
- No
Does your pet have access to wildlife or cattle?
- Yes
- No
Consent
I am the owner/agent for described animal, and authorize, and request the above services be performed for my pet. I can be reached at:
Phone
Consent & Signature
I give my consent and signature.
Client Name
First Last
Date
Date Format: MM slash DD slash YYYY

Δ

Contact

Phone: 214-328-9935
Email: edvcgeneral@sbcglobal.net

8541 Ferguson Road
Dallas, TX 75228

Hours

Monday & Thursday: 7:30 am – 8:00 pm
Tuesday, Wednesday & Friday: 7:30 am – 6:00 pm
Saturday: 8:00 am – 2:00 pm
Sunday: Closed

*The second Wednesday of each month – Closed from 1 pm-3 pm for our monthly staff meeting.

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Home
About Us
- Meet Our Team
- Policies & Payment Options
New Clients
Services
Pet Health
Client Forms
Contact
- Book Appointment
Pharmacy

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