Required only for curbside (not needed if you are coming inside):
Phone number to be used at this appointment:

Car make and color:

It is OK to give your pet clinic treats? (please bring your own for us to use if not)
YesNo

Your Pet's Diet:

Your Pet's Current Medications and Supplements:

Is your pet currently receiving parasite prevention?
YesNo
If yes, please tell us the brand and type of parasite prevention.

What preventative refills/doses would you like today? Please choose: Heartgard Plus, Nexgard, Frontline Gold, Revolution. We recommend year-round heartworm prevention (12 months) with Heartgard. We recommend Nexgard (oral) or Frontline Gold (topical) for flea and tick prevention, offered in 6 or 12 packs.

What is the main reason for your visit today?
Wellness/vaccinesMedical concern (Noted below)

How is your pet’s appetite?
---normalincreaseddiminished

Have you noticed any change in water consumption?
---morelessno change

Have you noticed any diarrhea or changes in stool?
YesNo

Have you noticed any vomiting?
YesNo
If your pet is vomiting is there anything he/she could have eaten or chewed up that is toxic or might be dangerous (clothing, chew toys, etc)? If yes, please explain:

Have you noticed any coughing/sneezing/discharge or other respiratory signs?
YesNo
If yes, please explain:

Have you noticed any limping/pain/stiffness or other mobility issues?
YesNo
If yes, please explain:

Have you noticed any skin or ear issues, such as itching/head-shaking/chewing/scooting?
YesNo
If yes, please explain

Have you noticed any new lumps or changes in existing lumps?
YesNo

Do you have any other questions or concerns you would like to discuss at today's visit? ( 860 characters left)

For this appointment, I understand that:

1. Masks are required when entering the clinic building.
2. Pets must be on leash with secure collar or in a carrier.

Signature (Please type your name in lieu of a signature)

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