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 indoor cats

Yes
No

My dog is exposed to outdoor cats

Yes
No

Do you take your dog to the dog park?*

Yes
No

Do you take your dog to boarding?*

Yes
No

Do you take your dog to grooming?*

Yes
No

Do you take your dog to the pet store?*

Yes
No

Do you take your dog camping?*

Yes
No

Do you take your dog hunting?*

Yes
No

Do you take your dog to woods/trails/hiking?*

Yes
No

Do you take your dog swimming?*

Yes
No

Do you take your dog to therapy/nursing home/hospitals?*

Yes
No

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 dog been vomiting?*

Yes
No

Has your dog had diarrhea?*

Yes
No

Has your dog been limping?*

Yes
No

Has your dog been itching?*

Yes
No

Has your dog had a change in appetite?*

Yes
No

Has your dog had a change in thirst?*

Yes
No

Has your dog had a decrease or increase in urination?*

Yes
No

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

Would you like your dog to receive a nail trim ($23.25 plus tax)*

Yes
No

Would you like your dog to receive anal gland expression ($33.30 plus tax)*

Yes
No

Would you like your dog to receive ear cleaning ($23.20 plus tax)*

Yes
No

Would you like your dog to receive a 4dx Heartworm/Tick Disease Screening test ($75.50 plus tax)*

Yes
No

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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