Animal Doctor Blue Hills Your Other Family Doctor CANINE WELLNESS First name * Last name * Preferred contact number. * Patient name * NEW PATIENTS ONLY: How long have you had the patient? NEW PATIENTS ONLY: Where did you get him/her? NEW PATIENTS ONLY: Is the patient microchipped? Yes No Unsure NEW PATIENTS ONLY: Vaccination history (be specific) NEW PATIENTS ONLY: Does the patient have any underlying conditions? Yes No Unsure NEW PATIENTS ONLY: If yes, please explain. How is the patient? Any vomiting/diarrhea/coughing/sneezing out of the ordinary? * Vomiting Diarrhea Coughing Sneezing Nothing out of the ordinary Do you have any (other) dogs and/or cats at home that have not visited the veterinarian in the past year? * Yes No Does your pet have wildlife exposure (including backyard)? * Any history of a vaccine reaction? * Yes No Unsure If yes, what vaccine and what reaction? Is the patient on any medications? * Yes No If yes, include the dosage and frequency. We recommend all pets have a fecal float to check for intestinal parasites performed annually. Are you interested in this? * Yes No Unsure Are you administering heartworm preventative? What type and how often? * Are you administering flea/ tick preventative? What type and how often? * What kind of food are you feeding? How much per day? Table scraps/ treats? * Do you have any additional questions or concerns you would like to address with the Doctor today? * Submit If you are human, leave this field blank.