Annual Pet History Form in Belle Vernon, PA

Owner Contact Information

Name

First Last

Cell Phone to reach during visit*

Pet's Name

Is your pet taking any medications?*

If so, please list them here

What percentage of time does your pet spend outside?*

Have you seen any fleas or ticks on your pet?*

Does your pet come into contact with other animals not in your home? (Check all that apply.)

Does your pet have exposure to water sources/wildlife. i.e. Rabbits, deer, turkey, creeks/streams, puddles, etc.?

What's the reason for your visit? (Check all that apply)

What tick/flea/heartworm prevention is your pet on? (Check all that apply.)

Brand Name*

Please refill my pet's heartworm or flea prevention. This is recommended once monthly, given year-round.*

If yes, please indicate the number of doses requested: 3/6/12 months

My pet's diet consists of: Brand, Type (Wet/Dry), Amount Fed, Number of Feedings, Table Food, Treats, etc.*

Other procedures requested:

Are there any concerns for the following: (Check all that apply.)

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?*

Do you need any refills of medication?

If yes, please indicate the names of the medications needed

Please complete my pet's annual preventative bloodwork (Geriatric bloodwork, Heartworm/Tickborne Disease Test, etc.)

Do you need an estimate prior to visit?

Any additional information you feel would be helpful for the doctor?