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 OneDOGCATDo you have health insurance on your pet?YesNoPlease 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?YesNoLiving Environment (select one):indooroutdoorbothAppetite (select one)normalincreaseddecreasedDrinking (select one)normalincreaseddecreasedBrand of foodAttitude (select one)normal-happylethargicHave 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 productyesnounsureif yes, productAre you using a flea/tick prevention productyesnounsureif yes, productAny regular medications /supplements administered at homeyesnoif 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]YesNoWould you like to upgrade to a 3 year DHPP vaccine if your dog qualifies (select one): [+$40]YesNoCATWould you like to upgrade to 3 year rabies vaccine if your cat qualifies (select one): [+$65]YesNoIs your cat (select):INDOOROUTDOORBOTHFELEUK vaccine recommended: [1 yr +$32, 3 yr +$50]YesNoWould you like to run a general health screening blood work panel with today's visit to check for major organ function: [$175]YesNoDoctor Discretion - strongly recommended for >5 year old and encouraged if <5 years old.
