Wellness Check-in Form Pet’s Name:*Owner’s (first & last) Name*Parking Spot #(office use only).Address* Street Address City State / Province / Region ZIP / Postal Code Alternate phone #Email Phone number to be reached at for today's visit:*Select One DOG CAT Do you have health insurance on your pet? Yes No Please check areas of insurance: Chinese Herbal Medicine Homeopathy Cold Laser Therapy Muscle Testing Reiki Energy Balancing VOM (Veterinary Orthopedic Manipulation, similar to chiropractic in humans) Muscle Therapy Craniosacral Therapy Appointment QuestionnaireDID YOU BRING A FECAL SAMPLE? Yes No Living Environment (select one): indoor outdoor both Appetite (select one) normal increased decreased Drinking (select one) normal increased decreased Brand of foodAttitude (select one) normal-happy lethargic Have you noticed any of the following: Select All vomiting diarrhea sneezing coughing limping shaking head seizures pain when urinating/defecating lumps/bumps (location) Are you using a heartworm prevention product yes no unsure if yes, productAre you using a flea/tick prevention product yes no unsure if yes, productAny regular medications /supplements administered at home yes no if yes, what medication/dosages/frequency:Comments / concerns about the above:Does your pet need (select applicable) nail trim anal glands expressed Does your pet need any medication / food refills? (ex: Heartworm, Thyroid, Royal Canin wet food, etc…)DOGWould you like to upgrade to 3 year rabies vaccine if your dog qualifies (select one): [+$28.50] Yes No Would you like to upgrade to a 3 year DHPP vaccine if your dog qualifies (select one): [+$40] Yes No CATWould you like to upgrade to 3 year rabies vaccine if your cat qualifies (select one): [+$65] Yes No Is your cat (select): INDOOR OUTDOOR BOTH FELEUK vaccine recommended: [1 yr +$32, 3 yr +$50] Yes No Would you like to run a general health screening blood work panel with today's visit to check for major organ function: [$175] Yes No Doctor Discretion - strongly recommended for >5 year old and encouraged if <5 years old.
