Curbside Dog Annual Exam and Vaccine Appointment Questionnaire

Please fill out this form for existing appointments only. (*required)

Your First Name:
Your Last Name:
Phone:
Email:
Your Pet's Name:

  

What phone number will you be available at during your pet’s appointment and whom should we be speaking with?

Would you like us to call you with an estimate for today’s visit?
YesNo

Which vaccines do you wish to have your pet updated on (mark all that apply)?
RabiesDHPPLeptoLymeBordetellaInfluenza

Any previous vaccine reactions (if so please explain)?
YesNo

Do you want us to run a 4DX test today (blood test to check for heartworm, Lyme, Ehrlichia, & Anaplasomosis)?
YesNo
Recommended to test annually on all dogs and required in order to refill heartworm medication.

Do you need a refill on Heartgard (heartworm prevention)?
YesNo
If yes, do you need a 3 pack, 6 pack, or 12 pack?:

Do you need a refill on Nexgard or Frontline Gold (flea/tick prevention)?
YesNo
If yes, do you need a 3 pack, 6 pack, or 12 pack?:

Do you want us to obtain & send out a stool sample to the lab (checks for intestinal parasites)?
YesNo

Do you want us to run a preventative care bloodwork profile (checks red & white blood cells, platelets, and organ function)?
YesNo
Recommended to test annually, but is optional.

What brand of dog food are you feeding your pet?

How much per feeding and how many times a day?

Any coughing or sneezing?

Any vomiting or diarrhea?

Any change in appetite or thirst?

Any observed lumps/bumps?

Any observed soreness or stiffness after resting or exercise?

Any observed change in weight?

Any medications currently taking and dosages:
YesNo

If yes, enter all medications, dosage, and how many times a day it is administered:

Is your pet allergic to any medications?
YesNo
If yes, enter medication(s):

Any other problems or questions you would like the doctor to address at today’s visit?

Signature (Please type your name in lieu of a signature)