"*" indicates required fields EmailThis field is for validation purposes and should be left unchanged. **Patients are triaged prior to being seen by a doctor and will be seen in the order of urgency. The doctor will call you once your pet has been evaluated** General InformationOwner's Name* First Last Pet's Name*Appointment Date* MM slash DD slash YYYY Date* MM slash DD slash YYYY I am over 18 years of age:* Yes No Pet Housed:* Indoor Outdoor Both Phone # we can reach you at today:*Email* Would you like to receive text messages about your pet’s progress while they are in the clinic?* YES NO Number to text*If your pet has been seen at another clinic, is it ok to request records from the previous clinic?* Yes No Clinic Information*Clinic NameClinic Number A routine wellness exam($42) is required once a year to ensure the health and well being of your pet. A new puppy/kitten wellness exam($49) is done at the first visit of any pet under the age of 1 year and includes a puppy/kitten care kit. (Up to $60 in value) Please choose the appropriate vaccinations and tests due for your petCanine Rabies - $30 DHLP (Distemper) - $38 Lyme - $46 Lepto Only - $29 Bordetella (Kennel cough) - $33 Heartworm/Lyme 4dx Test(Blood draw) - $54.00 None Due Unsure Feline Rabies- $30 FVRCCP (Feline Distemper)- $29 Feleuk- $36 Feleuk/FIV Test(Blood Draw)- $54.00 None Due Unsure Extras Nail Trim - $28 Anal Gland Expression - $36 Fecal (basic) - $47.99 Does your pet need any flea, tick, or heartworm preventative today? Yes No IF YES, please select the number of doses you would like from the following:Canine Preventatives:Bravecto- 12 week flea/tick chewable tablet (ages 6 months+)Simparica Trio- Monthly flea/tick/heartworm/roundworm/hookworm chewable tablet (ages 8 weeks+)Sentinel Spectrum- Monthly heartworm/hookworm/roundworm/whipworm/tapeworm (ages 6 weeks+)Vectra- Monthly flea/tick topical (ages 8 weeks+)Feline Preventatives:Revolution- monthly flea/ear mite/hookworm/roundworm topical that comes with a free dose of Cestex which is an oral tablet that treats tapeworm (ages 8 weeks+)Bravecto- 12 week flea/tick topical (ages 6 months+)If you have any health concerns, please specify:Signature*Date* MM slash DD slash YYYY
