Veterinary K9 Check-InName First Last Pet Name First Pet Age Puppy Adult SeniorPet Sex Male FemaleDate of Visit MM slash DD slash YYYY Reason for VisitHAS YOUR PET EVER HAD A VACCINE REACTION? Yes NoDOES YOUR PET HAVE ANY MEDICATION ALLERGIES OR INTOLERANCES? Yes NoMy pet is current on all vaccines to my knowledge: Yes NoIf your pets had their vaccines completed at another vet clinic please enter the name and city, state of that clinic:Vaccines DHPP RV Bordetella Lepto Microchip K9 Influenza LymeTests Heartworm Test Fecal Wellness Panel Senior Panel Pre-op Panel OtherProcedures Nail Trim ( -50lbs $15 / +50lbs $25) Anal Glands ($16.50) Sanitary Clip ($10) Microchip ($42) Ear Cleaning ($16.50)Does your dog live…….. Indoor Outdoor Indoor/OutdoorDo you have a fenced in backyard? Yes NoDo they go swimming, hiking or hunting or have access to wildlife (rodents, etc)? Yes NoDoes your Pet have a Microchip? Yes NoMicrochip #Brand of food fed:Please select the type of food.CannedDryBothAmount of food fed:How often is your pet fed? 1x Daily 2x Daily 3x Daily Treats Offered Yes NoTable Food Yes NoHave there been any changes in your pet’s appetite? Yes NoDecreased or Increased for how long?Have there been any changes in your pet’s water intake? Yes NoDecreased or Increased for how long?Medications/Parasite PreventionsCurrent Medications or Supplements: Flea PreventionProductDate of last dose1mth, 6mth or 12mth HW PreventionProductDate of last dose1mth, 6mth or 12mth Health StatusVomiting/DiarrheaPlease explain, how often, duration and appearanceCoughing/Sneezing/Nasal dischargePlease explain, how often, duration and appearanceLumps/BumpsPlease explain: Where are they located? How long have they been present? Has there been any color or size change?Itching/Hair loss/Skin lesionsPlease explain where and duration:Limping/LamenessPlease explain, which limb and how long:Have there been any changes in your pet’s behavior?If yes, please explainAny Other Problems that you have noticed? *Bad Breath *Loss of Balance *Breathing Problems *Difficulty rising *Change in sleeping habits *Changes in Hair Coat *Excessive Frequency of Urination *Excessive amounts of Urine *Scooting *Straining to Urinate/Defecate *Bleeding gums *Shaking Head *Squinting/runny eyes *Abnormal BM’s *Loss of Energy *Behavior Problems- Aggression, Storm phobia or Separation AnxietyDuration of these problems?Any Other problems/concerns that you would like to discuss with the Doctor?Are the any pre-existing health issues that we need to be aware of?Mobile PhoneHome PhoneEmail Best time to call:OK to text or email?In lieu of a physical signature, I agree and have checked to be certain the information I am submitting is correct for my pet's visit.
