"*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Checklist for Wellness AppointmentsClient's Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Pet's NameVerification* Verify client contact information to ensure it is current (name, address, phone, e-mail)Basic Information*AgeWeightTemperaturePulseRespirationSex* Male Intact Male Neutered Female Intact Female Spayed Reason for today's visit*Is there anything else you want to be sure to discuss with the doctor today?*DietWhat food are you feeding?*How much do you feed?*How often do you feed?*What kind of treats/snacks/table scraps/chews do you give your pet?*Current medications*What heartworm preventative do you give your pet?*What day of the month do you give your pet's heartworm preventative?*What flea/tick preventative do you give your pet?*How often?*Does your pet have a microchip?* Yes No What dental care do you provide for your pet at home? (Check all that apply.) Brush teeth Oral rinse or gel Dental diet CET Hextra Chews Greenies Drinking water additive (i.e. CET AquaDent or BreathaLyser) Other If other, please specify*Are other pets living at your home?* Yes No Pets at home*SpeciesPet Name Add RemoveDoes your pet need a nail trim today?* Yes No Has your pet been seen elsewhere for medical care since we last saw him/her?* Yes No If yes, when, where and what was done?When?Where?What?Any bumps or skin masses that the doctor should be aware of?* Yes No If yes, where, when was it seen, any changes?.Where?When?Changes?Does your pet have any of these symptoms? (Check al that apply.) Coughing Diarrhea Sneezing Excessive Drinking Vomiting Excessive Urination
