Well Pet Exam Drop Off Form

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Thank you for taking the time to fill out this form. This information will ensure your pet gets the preventative care she or he is due for.

Client Name*
First Last
Pet Name*
Species*
Breed (if known)*
Sex*
- Intact Male
- Neutered Male
- Intact Female
- Spayed Female
Age (if known)*
Reason For Visit*
Please describe any additional services or preventative products you would like to request:*
Has your pet experienced any of the following in the past week? (check all that apply)
- Vomiting
- Diarrhea/abnormal stool
- Excessive itching or head shaking
- Coughing or sneezing
- Increased/Decreased appetite
- Limping
- Scooting
- Increased/Decreased Water Consumption
- Lethargic
What heartworm and flea/tick preventatives do you use? How often do you use them?
Do you need refills today? (If yes, please specify: single dose, 6 month supply, 1 year supply)
What other medications does your pet take regularly?
Please list any supplements the pet is taking?
Do you need a refill of any other medication?
What food do you have your pet on? (include feeding amount and frequency)
Is the pet indoor or outdoor?
Does your pet have ANY allergies. Medication, food , etc?
Is your pet allowed treats during visit?
Has your pet ever exhibited any abnormal vaccine reactions? (If yes, please explain)
Does your pet have any anxiety or stress when coming to the vet? (If yes, please describe how we can improve their visit, or what treats can be given)
What is the best phone number to reach you at during the appointment?*
Your pet's technician will go over the exam findings at the time of pick-up. Please specify here if you would prefer to speak with the doctor regarding the exam.*
- Speak with Doctor
- Speak with Technician
*Upon arrival if your pet is found to have fleas, they will receive a Capstar to kill any adult fleas present, regardless of any flea preventative administered at home.

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Monday	7:30am – 6:30pm
Tuesday	7:30am – 6:30pm
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Saturday	7:30am – 6:30pm
Sunday	7:30am – 6:30pm

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Well Pet Exam Drop Off Form

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