Feline Wellness Form
Feline Wellness Form
General Information
Today’s Date
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Date of Appointment
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Client Name
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Client Name
First Name
First Name
Last Name
Last Name
Phone Number
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Email
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Patient Information & History
Cat’s Name
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How has your cat’s overall health been since the last visit?
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Excellent – No concerns
Good – Minor concerns
Fair – Some concerns
Poor – Significant concerns
Any new health issues or concerns to discuss?
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What medications, supplements, or treatments does this cat receive?
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What brand & form of food are you feeding this cat? (ex: Purina Pro Plan, Hill’s Sensitive Skin & Stomach, etc)
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How much food are you feeding this cat and how often? (ex: 1/2 cup twice daily)
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Any changes in eating, drinking, urination, defecation, or behavior since last visit?
Yes
No
Please explain changes in eating, drinking, urination, defecation, behavior
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Have you noticed any NEW lumps or bumps on your cat?
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Yes
No
Where are the new lumps or bumps?
Indoor/Outdoor Status
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Indoors only
0-25% outdoors
25-50% outdoors
50-75% outdoors
75-100% outdoors
Prevention & Services
What brand of heartworm prevention is this cat currently on?
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When did this cat receive their last dosage of heartworm prevention?
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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 cat currently on?
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When did this cat receive their last dosage of flea & tick prevention?
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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 cat since the last visit?
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Yes
No
Does this cat go to any of the following? (please select all that apply)
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Boarding
Grooming
Pet Stores
None of the above
What medication(s), monthly preventative(s), or prescription food do you need refilled today?
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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 cat need any additional services while with us today?
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Nail trim
Anal gland expression
None
Senior Wellness Bloodwork is recommended for cats over 7 years of age. Would you like to move forward with this testing?
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Yes, please proceed with the recommended wellness testing for my cat
I’d like to learn more at my cat’s drop off
No, I prefer not to move forward with this testing at this time
Consent to Treatment
Does this cat have a history of requiring injectable sedation due to high fear, anxiety, stress, or aggression?
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Yes
No
*Patient charts will be reviewed by staff upon receipt. If your cat’s chart states injectable sedation is required and “no” is selected, we will have you sign documents at drop off*
Authorization for Injectable Sedation
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Please remember to give pre-visit medications (trazodone, gabapentin, acepromazine) as prescribed the evening before and 2-3 hours prior to your appointment
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Agree
I authorize the following monetary amount for additional services outside of the cost of the annual wellness package
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$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.
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Yes
No
Drop-offs are triaged and worked on in between scheduled appointments
Signature
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Submit
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