CompanyThis field is for validation purposes and should be left unchanged.Owner's Name First Last Pet's NameAny change in address? 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Briefly why is your pet coming in?DIETWhat kind of food is your pet on and how much do you feed per day?Any special diet considerations (Sensitivity or Prescription)?MEDICATIONS/SUPPLEMENTSIs your pet taking any medications or supplements? Yes No If yes, what medications/supplements? Add RemoveBLOODWORKWe minimally recommend that all dogs, > 5 years old receive yearly bloodwork to check liver, kidneys, pancreatic function, & a complete blood count to test for infections, anemias, dehydration, and electrolytes. This is also a good baseline if anything ever happens or if there is an underlying unknown disease to truly determine that your pet is healthy and to help address minor issues before they become major, uncontrollable issues. Bloodwork is required for certain prescription medications. Would you be interested in blood work at your visit? Yes No HEARTWORMSThese are parasites that are given to indoor & outdoor dogs by mosquitoes. All dogs should be on prevention every month, year round. When a mosquito with heartworm disease bites a dog it transmits larva which grow into small worms called microfilaria over the course of a month. Heartworm prevention can only kill the larva, not an adult worm. It only takes ONE infected mosquito to transmit this disease.Is your pet on monthly Heartworm Prevention? Yes No If Yes, What kind?INTESTINAL WORMSDogs may become infected with hookworms, roundworms, whipworms, & tapeworms. Both hookworms & roundworms are contagious to humans, especially children or the immunocompromised, causing blindness, & skin infections. Monthly heartworm preventions certain parasites but will completely rid the infection. Please submit a fecal sample yearly to assess for these parasites OPTIONAL VACCINES - These are vaccines that are dependent on your pet's lifestyle and vaccine history.KENNEL COUGH Infectious respiratory virus which suppresses the immune system and can cause a pneumonia May be caused by bordetella bronciceptica, adenovirus or parainfluenza virus. We recommend and require all boarding or groomed dogs to be vaccinated every 6 months with Intra-trac III vaccine that covers all the above to hopefully prevent the infection or at least decrease the symptoms. a. Does your dog get boarded or groomed? Yes No b. Do you live in a suburb or walk your dog in areas that they may be exposed to other dogs? Yes No CANINE INFLUENZA VACCINE A new flu virus of dogs that can potentially be fatal or cause a life threatening penumonia. Dog influenza can be obtained from human influenza. It is required for most boarding facilities and some groomers. We have seen several confirmed cases this year. This vaccine also needs a booster in 3 weeks if you pet has never had one. Are you interested in an influenza vaccine Yes No LYME DISEASE VACCINE A very common vaccination for the mid-west to prevent a potentially deadly disease spread by deer ticks. We have seen several positives here in Holt – Highly recommended if you have tall grass, trees, go hiking, or camping. Lymes disease can go without symptoms for several years and can be difficult to cure. Lymes can cause kidney failure, joint pain and inflammation, lameness, fevers, generalized lethargya. Would you like to test your dog to see if they have been exposed to lymes disease (recommended if you have seen an attached tick > 4 weeks ago Yes No b. Would you like to vaccinate your pet against lymes disease? Yes No FLEA AND TICK PREVENTIONThere are multiple kinds of prevention that depends on your pet and your environment. Please ask our staff which would be right for you.1. Is your pet on flea/tick prevention? Yes No If yes, What kind?2. Do you have any questions about prevention? If yes please explainIS THERE ANY OTHER QUESTIONS OR CONCERNS WITH YOUR PET TODAY?
