Wellness Form Wellness and Vaccination Client Contact Information Owner Name * Owner Name First First Last Last Phone Number * Email Best way to reach you today? Call cell phone Text cell phone Email Pet Information Pet Name Has there been any vomiting? Yes No Has there been any diarrhea? Yes No Is your pet eating and drinking well? Yes No When was your pet's last normal meal? This morning Yesterday evening Yesterday morning More than 24 hours ago What does your pet eat, how much, and how often? Is your pet urinating and defecating normally? Yes No Is your pet coughing or sneezing? Yes No Please describe the coughing or sneezing - and when did it start? Have you noticed any stiffness, soreness, or lameness when your pet is moving around? Yes No Please describe the stiffness, soreness, or lameness - and when did it start? Please list all the medications, supplements, and OTC drugs your pet is currently taking. Please list the dosage if possible. When was the last time your pet took their medications? What preventions is your pet taking? Do you approve refills of previous purchased preventatives? Yes No For heartworm prevention: Proheart6 injection every 6 months ProHeart 12 every 12 months Monthly topical Advantage Multi Monthly topical Revolution Monthly oral Trifexis Monthly oral Heartgard Other Brand not listed Simparica Trio Revolution Plus - for cats None For flea and flea/tick prevention: Bravecto - Oral Bravecto - Topical Trifexis Nexguard Revolution Advantage Multi Simpirica Seresto Scalibor Credelio None - please administer oral Bravecto None - please apply topical Bravecto Other Brand not listed None New Option New Option New Option New Option For dental disease prevention: Oral Chews Oral Rinse Oral Diet Brush Teeth daily/2-3X a week All of the above None of the Above - can not perform None of the Above - teach me more If your pet is due, do we have permission to perfom a heartworm test? Yes No Do you need anything refilled (meds, foods, preventions)? Please let us know what and quantity. Do you need us to administer medication/prevention while your pet is here? Are there any medical concerns we should know about? Has your pet been seen by another veterinarian recently? You can upload their history here! Drop a file here or click to upload Choose File Maximum upload size: 52.43MB If you do not have your pets history on hand, do we have permission to call for history? Yes No Name of your pet's last clinic: Does VO Vets have the approval to perform needed vaccinations, heartworm/flea prevention, preventative testing, and wellness lab work up to $500 prior to calling with an exam report? If not, we will call with an estimate and doctor recommendation after an exam has been performed. Yes No Signature Clear If you are human, leave this field blank. Submit
