Canine Wellness Form
Canine Wellness Form
General Information
Today’s Date
*
Date of Appointment
*
Client Name
*
Client Name
First Name
First Name
Last Name
Last Name
Phone
*
Email
*
Patient Information & History
Dog’s Name
*
How has your dog’s overall health been since the last visit?
*
Excellent – No concerns
Good – Minor concerns
Fair – Some concerns
Poor – Significant concerns
Any new health issues or concerns to discuss?
*
What medications, supplements, or treatments does this dog receive?
*
What brand & form of food are you feeding this dog? (ex: Purina Pro Plan, Hill’s Sensitive Skin & Stomach, etc)
*
How much food are you feeding this dog and how often? (ex: 2 cups twice daily)
*
Any changes in eating, drinking, urination, defecation, or behavior since last visit?
Yes
No
Please explain changes in eating, drinking, urination, defecation, behavior
*
Have you noticed any NEW lumps or bumps on your dog?
*
Yes
No
Where are the new lumps or bumps?
Prevention & Services
What brand of heartworm prevention is this dog currently on?
*
When did this dog receive their last dosage of heartworm prevention?
*
Within the last 30 days
Within the last 3 months
More than 3 months ago
Not currently on a heartworm preventative
What brand of flea & tick prevention is this dog currently on?
*
When did this dog receive their last dosage of flea & tick prevention?
*
Within the last 30 days
Within the last 3 months
More than 3 months ago
Not currently on a flea & tick preventative
Have you seen any flea, ticks, or parasites on this dog since the last visit?
*
Yes
No
Does this dog go to any of the following? (please select all that apply)
*
Boarding or Doggy Daycare
Grooming
Dog Parks
Pet Stores
None of the above
What medication(s), monthly preventative(s), or prescription food do you need refilled today?
*
Options for prescriptions: refilled the prescription in clinic, authorize prescription via our VetCove online pharmacy, or pick up a paper prescription for third party pharmacies. We do not fax prescriptions or authorize prescriptions over the telephone.
Does this dog need any additional services while with us today?
*
Nail trim
Anal gland expression
None
Senior Wellness Bloodwork is recommended for dogs over 7 years of age. Would you like to move forward with this testing?
*
Yes, please proceed with the recommended wellness testing for my dog
I’d like to learn more at my dog’s drop off
No, I prefer not to move forward with this testing at this time
Consent to Treatment
Permission to administer oral anti-anxiety medications?
*
Yes
No
The anti-anxiety medications are intended to address specific neurotransmitters associated with fear, anxiety, or stress related to the veterinary setting. The goal is to help make your pet’s veterinary visit more enjoyable and less stressful. Medications can help to reduce stress and anxiety so the veterinary team can work to change the way your pet feels about specific procedures such as being handled or receiving a vaccination.
Does this dog have a history of requiring injectable sedation due to high fear, anxiety, stress, or aggression?
*
Yes
No
*Patient charts will be reviewed by staff upon receipt. If your dog’s chart states injectable sedation is required and “no” is selected, we will have you sign documents at drop off*
Authorization for Injectable Sedation
*
signature
keyboard
Clear
Please remember to give pre-visit medications (trazodone, gabapentin, acepromazine) as prescribed the evening before and 2-3 hours prior to your appointment
*
Agree
I authorize the following monetary amount for additional services outside of the cost of the annual wellness package
*
$250
$400
None
I understand that NHPC may not contact me regarding the status of my pet prior to 4:00pm, unless there is an emergency.
*
Yes
No
Drop-offs are triaged and worked on in between scheduled appointments
Signature
*
signature
keyboard
Clear
Submit
If you are human, leave this field blank.
× Close Panel
