Annual Exam/ Vaccination Intake Form

Date of Appointment

Date

Full Name*

First NameLast Name

Contact Number For During Exam*

Your pet has been scheduled for an annual examination and update of vaccinations. Please fill out this form completely to the best of your ability prior to your appointment.

Please bring a fresh stool sample from your pet to their appointment.

Ticks and tick transmitted disease have become more prevalent. We recommend an annual blood test for our canine patients only called a 4Dx to test for the presence of tick transmitted disease (Lyme, Ehrlichia, Anaplasmosis) and heartworm disease. The cost for this blood work is $77.87 + tax. We do recommend blood work to test organ functions and the overall health of your canine family member. We do offer different panels depending on their known health status or age. The Basic Wellness ($149.00 plus taxes) can be for younger dogs or ones with no known heath issues. The Comprehensive Wellness ($241.90 plus taxes) is more in-depth testing for older dogs or ones having current health issues. Both of these packages do included the 4DX testing. Please feel free to ask any questions regarding these tests if you need further clarification. Please check for:

4Dx ($77.87 + tax)Basic Wellness ($149.00 + tax)Comprehensive Wellness ($241.90 + tax)I decline blood workI would to discuss this further prior to deciding

Due to the prevalence of Lyme disease in our area, we are now recommending the lyme vaccine for dogs that are at an increased risk. The lyme vaccine can be given today if you elect to do so (no additional cost), and requires a booster in one month ($94.76). It is then included annually with your vaccinations*

Yes, I would like my pet vaccinated for lymeNo, I decline the lyme vaccine

During your pet's visit, in addition to love and attention, we like to give treats (where appropriate). We use Crumps all natural baked liver (beef) treats. Please confirm you are okay with your pet receiving treats.*

Yes, my pet can have treatsNo treats thank you

Is your pet still eating normally?

YesNo

What is your pet's regular diet? (Brand, kibble/canned/raw, feeding schedule and amount):

Do you give your pet any treats, dental chews, table scraps, etc- please list:

Have you noted any changes in the amount or frequency that your pet drinks?

YesNo

Is your pet having normal bowel movements (frequency/consistency)?

YesNo

Is your pet having normal urinations?

YesNo

Has your pet had any recent vomiting or diarrhea (past month)?

YesNo

Any sneezing or coughing, or discharge from the eyes/nose?

YesNo

Any changes in activity level/behaviour

YesNo

Does your pet go to groomers,dog parks,boarding kennels, or interact with other animals?

YesNo

Has your pet had any history of travel?

YesNo

Does your pet hunt or scavenge and/or eat small mammals?

YesNo

Is your pet prone to ear infections, or skin allergies?

YesNo

Do you require any of the vaccinations discussed with you prior to them being given?

YesNo

Has your pet had any previous reactions to vaccines?

YesNo

Is your pet currently taking any medications or supplements?

YesNo

If yes, please list below

Do you need a refill of any medications or food today (please list):

Is your pet on flea/tick/heartworm prevention, if yes please list product and when the last dose was given below:

Are there any additional concerns that you would like the doctor to be aware of today? If yes, please list below.

Thank you for taking the time to complete our intake form. The information you provide is valuable and enables us to provide the best care for your pet. If there is anything else not on this sheet that you need discussed or evaluated, please communicate it to a team member prior to your appointment.

**We are accepting debit and credit payments only at this time**

Annual Exam/Vaccination Intake Form - Canine