Animal Doctor Westside 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? * If your pet is 7 years or older, we highly recommend senior testing. This involves blood testing and urinalysis to check organ function (kidneys, liver, thyroid, for example), and to screen for ailments more common in older pets. The cost is $185.00. Would you like to have this testing done on your pet? * Yes No Unsure My pet is under 7 years of age 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.