Pet’s Name: ____________________
1. What is your main concern for today’s visit?
2. Does your pet have insurance? If so, which company?
Trupanion
VPI
Healthy Paws Other: ____________
3. Is your pet currently on a monthly flea control?
Circle Brand: Revolution Sentinel Frontline
Other: ____________
Trifexis
Bravecto
4. Is your pet currently on a monthly de-wormer or heartworm preventative?
Circle Brand: Revolution Sentinel Heartguard Trifexis Interceptor Plus
Other: _____________
5. Does your pet interact with children? Yes
/
No
6. What diet is your pet currently eating? How much do you feed?
7. What medications and/or supplements is your pet currently taking? (please include dosages)
8. Do you need any refills of medications or food today? If so, which ones?
9. Has your pet traveled to Eastern WA, or outside of WA? Yes
/
No
10. Is your pet exhibiting any of the following symptoms?:
Coughing
Sneezing
Diarrhea
Vomiting
11. Nail trims are $15 and anal gland expressions are $26 with an office visit. Please circle if you
would you like either procedure performed today: TNT / AG
12. Would you prefer to be contacted by phone or email for your pet’s follow up instructions, lab
work, discharge information, etc.?
Phone / Email
Email address/Phone number:
13. Would you like an estimate for today’s costs? Please circle:
No estimate needed!
Yes, regardless of price
If over $100
If over $200
If over $300