This form will be used for any wellness examination on a pet.Print this formOwner's Name First Last Pet's NameIs your pet indoors only, outdoors only, or both? Indoors OutdoorsDo you have any other pets? Yes NoPlease DescribeDo you travel with your pet or have other animals visit? Yes NoDoes your pet go to the groomer or any boarding facility? Yes NoDoes your pet have a microchip and is up-to-date for your contact information? Yes NoWhat brand does your pet consume, the amount consumed in a day and is your pet given any treats?Does your pet have bad breath, drooling, or difficulty eating? Yes NoHas there been any changes in stools or urination (color, consistency, frequency, amount, straining, accidents etc.) in the past 12 months? Yes NoIf YES please describeIt is recommended that your pets feces be tested annually for internal parasites. Opt-out: Yes NoHas your pet had any vomiting or regurgitating in the past 12 months? Yes NoIs your pet currently on any preventatives? These include flea, tick, heartworm, gastrointestinal parasites, ear mites, etc Yes NoIf YES, please describe.If given preventives, has your pet missed any doses or have they been discontinued at any point?Has your pet been tested for heartworms and other bloodborne pathogens (Anaplasma, Ehrlichia, and Lyme for dogs or Feline Leukemia Virus and Feline Immunodeficiency Virus for cats) in the past 12 months? Yes NoAn annual heartworm check is required if on heartworm preventative. Opt-out Yes NoHas your pets blood and/or urine been tested for liver, gall bladder, pancreas, kidney, bladder health, thyroid, red blood cells, white blood cells and platelet values in the past 12 months? Yes NoDoes your pet currently take any medications or supplements? Yes NoIf YES, please describe.Has your pet been sick, ill, or had any surgeries in the past 12 months? Yes NoIf YES, please describe.PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SignatureDate MM slash DD slash YYYY CAPTCHAΔ
