Canine Wellness History Form Canine Wellness Profile Please fill out and submit this form prior to your dog's wellness appointment Pet's Name* Owner's Name* First Last How should we contact you during today's appointment (drop off appts only)?* NOT A DROP OFF PHONE TEXT Email* Enter Email Confirm Email Best Phone Number for Appointment Day*Date of Appointment* MM slash DD slash YYYY Has your pet ever had any vaccine reactions?* YES - Please also advise the staff of this at the time of your appointment. No Is your pet microchipped?* Yes - Please check the chip at this visit. No - Please microchip my pet at this visit. No - I am not interested at this time. Please see http://farmandfamilyvet.com/services/microchipping/ for more info.I feed my pet...* Dry food Canned food Treats People food Select all that apply.Brand of Food* Hill's Science Diet Purina ProPlan Royal Canin A Prescription Diet Dental Care - Do you give or do any of the following?* Teeth brushing regularly Dental Chews (Oravet, Greenies, etc.) Dental Rinses Annual Dental Exam & Cleaning None of these Is your dog taking heartworm preventative monthly?* Yes - every month Yes, but I've missed a month or two this year Yes, but not regularly at all No, not on preventative Annual heartworm testing and monthly preventative is recommended for all dogs.Is your dog getting flea/tick preventative monthly?* Yes - every month Yes, but I've missed a month or two this year Yes, but not regularly at all No, not on preventative Monthly flea/tick preventative is recommended for all dogs. Tick prevention is especially important, as we see many cases of Lyme disease which is carried by deer ticks.Does your dog have contact with other dogs outside of your family?* Grooming Boarding Training/Doggie Daycare Other NO - My dog doesn't have contact with other dogs. If so, Bordetella vaccine (kennel cough) is recommended.Is your dog at higher risk for Lyme disease?* Lives in the Country Goes camping/playing in the woods Frequently see ticks on him/her NO - None of these If you checked any of the first 3 boxes, your dog is at higher risk of Lyme disease and vaccination for Lyme is recommended.Services you would like performed today:* **Rabies vaccine (and registration if in Clark County) **DAPPv (Distemper/Parvo) if due Leptospirosis vaccine (annual for most dogs) Lyme vaccine Bordetella (Kennel Cough) vaccine **Heartworm Test Microchip Nails trimmed Express Anal Glands All dogs will get a full wellness exam. **These items are recommended for all dogs. A staff member will review your choices and let you know if there are any questions.Prevention Needed Prescribed or Refilled* Heartgard (heartworm prevention) Interceptor (heartworm prevention) Nexgard (flea/tick) Provecta (flea/tick) Whatever they got last year None Number of Doses Requested Anything else you would like the staff to know or questions you may have?*File Upload Drop files here or Select files Accepted file types: pdf, jpg, gif, png, jpeg, Max. file size: 128 MB. You may attach previous records from another vet clinic or shelter here if needed. Please use pdf or jpg if possible. Alternately, you can email them to farmandfamilyvet@gmail.com with your pet's first and last name as the subject.
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