Owner Information

Name*

First Last

Phone*

Email*

Date of My Pet's Appointment*

Pet Information

Name*

Is this pet new to us?

Date of Birth

Sex

Breed

Colour(s)

Markings

Microchip?

Tattoo?

Pet Medical History

My dog is...

My neighbourhood location is...

Number of dogs in my household

How long have you had your dog?

Where did you get your dog?

Is your dog exposed to other outdoor dogs?

Is your dog exposed to cats?

My dog is exposed to..

Check all that apply.

Indoor Cats
Outdoor Cats

Do you take your dog to...

Check all that apply.

Dog Park
Boarding
Grooming
Pet Store
Camping
Hunting
Woods/Trails/Hiking
Swimming
Therapy/Nursing Home/Hospitals

Do you take your dog on vacation?

Where do you take your dog on vacation?

Is your dog currently on heartworm prevention?

List any prescription or over the counter medication your dog is taking including flea products, vitamins, supplements, topical, etc.

What food does your dog eat and what treats do you feed?

Has your pet had any of the following?

Check all that apply.

Vomiting
Diarrhea
Limping
Itching
Change in appetite
Change in thirst
Decreased or increased urination

List any health or behavior concerns regarding your dog you would like the veterinarian to address today

Would you like additional services for your dog during this visit?

Check all that apply.

Nail trim ($23.25 plus tax)
Anal gland expression ($33.30 plus tax)
Ear cleaning ($23.20 plus tax)
4dx Heartworm/Tick Disease Screening test ($75.50 plus tax)
Other (specify below)

Other, please specify.

Have you noticed any lumps you would like to have checked?

Please provide details, including approximate location on your dog.

Senior Wellness Panel*/and or on chronic meds*

This is a comprehensive blood panel recommended yearly for all dogs over 6 years of age. Having bloodwork done for geriatric pets is crucial for longevity, early detection of disease and management of conditions. Approximate cost $245 (including cbc/chemistry/4dx heartworm/tick disease screening).

Dog Wellness Visit History Form

Owner Information

Pet Information

Pet Medical History

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