Wellness Exam / Annual Exam Form Owner Name* First Last Patient Name*Species*DogCatBreed*Sex*(Select one)*Neutered /SpayedIntactage*012345678910111213141516171819202122232425What medications is your pet currently taking and when was the last time it was given? Refills?*Is there a change in activity level?*YesNoBriefly ExplainWhat is your pet eating?*Any changes with urination or bowel movements?*YesNoBriefly ExplainAny known allergies or reactions to vaccines or medications?*YesNoBriefly ExplainIf your pet is due for a vaccine, heartworm test, or fecal exam, would you like us to proceed or would you like to be contacted first?*ProceedCall FirsWhich vaccines or tests? Rabies Distemper/Parvo Bordatella Influenza Leptosporosis Heartworm Test Fecal ExamWhich vaccines or tests? Rabies 1 year Rabies 3 year FVRCP Leukemia Heartworm Test Fecal ExamAfter examination by the doctor, may we proceed with tests/treatment?*YesPlease call firstBest contact person and number(s) for today:*Preferred pick up time:*Waiting outsidePickup timeAre there any other concerns or questions you may have?*YesNoIf yes, briefly explainWould you like to purchase Heartworm and Flea prevention today?*YesNoWhich brand?Payment Method* Cash Check Credit Card Care CreditSignature*PhoneThis field is for validation purposes and should be left unchanged.
