Wellness Visit Form

Client Name:*
Pet Name:*
Appointment Date:*
Appointment Time:*

: HH

MM
Reason for Visit:
FEEDING INSTRUCTIONS
Brand of Food
Type
Qty
Times/Day
CURRENT MEDICATIONS
Are you Giving Heartworm Pills?
- Yes
- No
Are you Giving Flea Prevention?
- Yes
- No
Include any over the counter medications and supplements.
PRESCRIPTION MEDICATIONS
Name & Strength
Qty
Times/Day
Special Instructions
Name & Strength
Qty
Times/Day
Special Instructions
Name & Strength
Qty
Times/Day
Special Instructions
Name & Strength
Qty
Times/Day
Special Instructions
Name & Strength
Qty
Times/Day
Special Instructions
Name & Strength
Qty
Times/Day
Special Instructions
ENVIRONMENT
Dogs - Where does your dog go?
(i.e. Dog park, groomer, forest preserve, etc.)
Cats- How much time spent outdoors?
Has your pet been eating and drinking ok?
- Yes
- No
Has your pet been drinking or urinating more?
- Yes
- No
If yes, please explain:
Has your pet been vomiting or experiencing diarrhea?
- Yes
- No
If yes, please explain:
Is your pet coughing or sneezing?
- Yes
- No
Does your pet have growths or bump that are new?
- Yes
- No
If yes, please explain:
How has your pets attitude/activity level been?
- Overactive
- Normal
- Lethargic
OTHER SERVICES NEEDED
Rabies Vaccination?
- Yes
- No
If yes, please select.
- 1 Year
- 3 Year
What County?
Nail trim?
- Yes
- No
Anal Glands?
- Yes
- No
Other Services Needed?
MEDICATIONS NEEDED
Heartworm Pills?
- Yes
- No
If yes, what Brand?
Qty
Flea and Tick?
- Yes
- No
If yes, what Brand?
Qty
Any refills?
- Yes
- No
If so, please list medication refills needed below:
Are there any other concerns?