"*" indicates required fields WILLOUGHB VETERINARY HOSPITALOwner's Name* Pet's Name* 1. Are you a NEW CLIENT, has it been a 1 year since you have been here or have you had any address or phone # change?* Yes No 2. Do you a have NEW PET?* Yes No 3. Why is your pet here today?* 4. Is your cat indoors or indoor/outdoors?* DIET:1. Is your cat free feed or meal feed* 2. Does your pet eat dry food, soft food, or both* 3. Any special diet considerations (Sensitivity or prescription)* BLOODWORK: We recommend that all pets, especially those > 10 years old receive yearly bloodwork to check liver, kidneys, pancreatic & thyroid function, as well as a complete blood count to test for infections, anemias, dehydration, & electrolytes. This is also a good baseline if anything ever happens or if there is an underlying unknown disease.1. Is your cat over the age of 10?* Yes No a. Are you interested in a SENIOR PROFILE that tests for all the above today?* Yes No 2. Is your pet on any medications?* Yes No a. What kind and how often?* 3. Do you know or are you interested in knowing if your cat has any pre-existing conditions?* Yes No We STRONGLY recommend at least a SMALL BODY FUNCTION TEST that checks for liver and kidney function (most medications are filtered through these organs), dehydration, & protein that may signify infection or other GI/kidney or liver diseases. We recommend this test ANNUALLY for ALL patients on chronic medications, especially those for arthritis or heart disease.a. Would you like one done today?* Yes No FELINE LEUKEMIA/ FELINE AIDS: Feline Leukemia is an incurable deadly disease that requires yearly vaccines to prevent 99% of the time. It is transmitted by touch and recommended for all multi-cat households or indoor/outdoor cats. Feline AIDS is an incurable deadly disease transmitted by bite wounds & has no vaccine at this time A yearly test is recommended for all indoor/outdoor cats. 1. Has you cat ever been tested?* Yes No a. When and whre?* 2. Would you like your cat tested for Feline Leukemia and Feline AIDS today?* Yes No 3. Since Feline Leukemia is only recommended for multi-cat households and indoor/outdoor cats, would you like yours vaccinated for it today?* Yes No INTESTINAL WORMS: Outdoor cats may become infected with hookworms, roundworms, whipworms, and tapeworms. Both hookworms and roundworms are contagious to humans, especially children or the immunocompromised, causing blindness, and skin infections. Please submit a fecal sample to assess for any internal parasites. IS THERE ANY OTHER QUESTIONS OR CONCERNS WITH YOUR PET TODAY?