First Name

Last Name

Contact Email Address

Contact Cell Phone

What is your pets Name?

How much does your pet weigh? (lbs)

Is your pet a dog or a cat? Is your pet a dog or a cat? Cat Dog

What heartworm and flea/tick preventive are you using? What heartworm and flea/tick preventive are you using? None Yes

Last Administered

What type?

Have you seen any fleas or ticks on your pet? Have you seen any fleas or ticks on your pet? No Yes

What brand of food do you feed your pet?

How much do you feed?

Do you provide any dental care for your pet? Do you provide any dental care for your pet? None Yes

Do you have other pets? Do you have other pets? None Yes

Are they currently vaccinated and on heartworm and flea preventive?

Does your pet go outside? Does your pet go outside? Daily for bathroom/walks 50:50 Indoor/Outdoor Outdoor all the time Indoor all the time

Does your dog: Does your dog: Board Visit groomer Dog Parks Obedience/Training Classes Contact Neighborhood Dogs

Is your cat: Is your cat: Friendly Shy Skittish Aggressive

Have you noticed any lumps or bumps on your Have you noticed any lumps or bumps on your No Yes

where have you seen these?

Have you noticed any of the following Have you noticed any of the following Coughing or Labored Breathing Limping Lethargy Increased Thirst Diarrhea Vomiting Not using the litter box Other

Please specify

When did you first notice any of the symptoms listed above?

Does your pet have any behaviors you wish you could change? Does your pet have any behaviors you wish you could change? No Yes

Please specify

Are there any additional health issues you'd like to discuss with the doctor? Are there any additional health issues you'd like to discuss with the doctor? No Yes

Please tell us more about these issues

Is your pet currently on any medications other than heartworm/flea prevention? Is your pet currently on any medications other than heartworm/flea prevention? No Yes

Please list them here