Well Visit Form - Grace Park Animal Hospital

Your Name *

First

Last

Your Pet's Name *

Appointment Date & Time *

We offer a Preventative Health Plan (PHP) which is a cost efficient and comprehensive wellness plan intended to make sure your pet remains in the best health possible. There are a variety of plan options that include a combination of vaccines, bloodwork, dental cleanings, and/or spay and neuter procedures.

That sounds great! Please tell me more about the PHP.
Thanks for letting me know, I'm not interested at this time.

Please list all medications that your pet is currently taking including the dose. (Don’t forget supplements!) *

What kind of food does your pet eat?

How much food do you feed your pet daily?

What type of Heartworm prevention is your pet receiving?

Other Heartworm Prevention:

What type of Flea/Tick Prevention is your pet receiving?

Other Flea/Tick Prevention:

What concerns/questions would you like addressed today?

What type of visit

Dog Visit
Cat Visit

Canine Risk Assessment

Tell us about your pet's lifestyle so we can help you choose the best vaccine protocol to keep her protected.

Does your pet spend any time outdoors in areas where wildlife, such as deer, foxes, raccoons, and opossums have access?

Yes
No

Does your yard contain trees and bushes, or does your property border woods or other non-developed areas?

Yes
No

Does your pet go outdoors:

off-leash in a fenced yard
roam freely
other

Do you walk on public greenways or other areas where you may have "pass-by" contact with other dogs?

Yes
No

Do you frequent dog parks, doggie daycare, boarding or grooming facilities?

Yes
No

Does your pet do any deep-woods hiking or go swimming in lakes or ponds?

Yes
No

Do you travel with your pet to New England or the Mid-Atlantic states, including Virginia?

Yes
No

Feline Risk Assessment

Tell us about your pet's lifestyle so we can help you choose the best vaccine protocol to keep her protected.

Which phrase best matches your cat's lifestyle?

Strictly indoors
Sometimes indoors, sometimes outdoors
Strictly outdoors

If indoors only, does your cat have access to a screened porch, patio, balcony, or other protected outdoor environment?

Yes
No

If indoors only, does your cat try to "dart" outside when there is an open door?

Yes
No

Does your cat interact with other cats that live outdoors or partially outdoors?

Yes
No

Does your cat spend any time at grooming or boarding facilities?

Yes
No

AUTHORIZATION

Your signature on this form indicates your understanding and agreement to the following policies:

Signature *

Clear Signature

Signed by (type name): *

Date Signed *

Date / Time

Date

Time

Looking for something else?

Canine Risk Assessment

Feline Risk Assessment

AUTHORIZATION

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