Wellness Visit Form Client Name:* Pet Name:* Appointment Date:* MM slash DD slash YYYY Appointment Time:* : Hours Minutes AM PM AM/PM Reason for Visit:FEEDING INSTRUCTIONSBrand of Food TypeWetDryQty Times/Day CURRENT MEDICATIONSAre you Giving Heartworm Pills? Yes No Are you Giving Flea Prevention? Yes No Include any over the counter medications and supplements.PRESCRIPTION MEDICATIONSName & Strength Qty Times/Day Special Instructions Name & Strength Qty Times/Day Special Instructions Name & Strength Qty Times/Day Special Instructions Name & Strength Qty Times/Day Special Instructions Name & Strength Qty Times/Day Special Instructions Name & Strength Qty Times/Day Special Instructions ENVIRONMENTDogs - Where does your dog go?(i.e. Dog park, groomer, forest preserve, etc.)Cats- How much time spent outdoors?Has your pet been eating and drinking ok? Yes No Has your pet been drinking or urinating more? Yes No If yes, please explain:Has your pet been vomiting or experiencing diarrhea? Yes No If yes, please explain:Is your pet coughing or sneezing? Yes No Does your pet have growths or bump that are new? Yes No If yes, please explain:How has your pets attitude/activity level been? Overactive Normal Lethargic OTHER SERVICES NEEDEDRabies Vaccination? Yes No If yes, please select. 1 Year 3 Year What County? Nail trim? Yes No Anal Glands? Yes No Other Services Needed?MEDICATIONS NEEDEDProheart 12 (This is a 12 month heartworm prevention injection)? Yes No Heartworm Pills? Yes No If yes, what Brand? Qty Flea and Tick? Yes No If yes, what Brand? Qty Any refills? Yes No If so, please list medication refills needed below:Are there any other concerns? Δ
