Canine Well Patient Drop Off Form

Client Info

Client Name

Patient Info

Do you provide dental care for your dog?
If no, are you interested in providing dental care?
General health questions regarding your pet
Has your pet had any Vomiting?
Has your pet had any Diarrhea
Has your pet had any Limping?
Has your pet had any Soreness?
Has your pet had any Coughing?
Has your pet had any Sneezing?
Has your pet had any Lethargy?
Has your pet had any Growths?
Has your pet had any changes on water consumption
Has your pet had any changes in food consumption
Has your pet had any changes in urination
Any chance your pet is pregnant?
We recommend annual blood work to screen for internal organ function, infections, and anemia - all items that cannot be detected on physical examination alone. Would you like to have a blood test performed on your pet (typical cost $95)
General questions to help us choose the best vaccination protocol for your pet:
Has your pet ever had a vaccination reaction?
Does your pet go to boarding or grooming?
Does your pet go to heavily wooded areas, lakes, or farms with cattle?
Does your pet go hunting?
Do you have any problems with ticks?
Does your pet have access to wildlife or cattle?
Preffered Doctor
Sign above