"*" 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. Why is your pet here today?*MEDICATIONS/SUPPLEMENTS:1. What kind of food is your pet on and how much do you feed per day?*2. Any special diet considerations (Sensitivity or Prescription)?*DIET:1. Is your pet taking any medications or supplements?* Yes No a. What medications/supplements?*BLOODWORK: We recommend that all dogs, > 5 years old receive yearly bloodwork to check liver, kidneys, pancreatic function, & a complete blood count to test for infections, anemias, dehydration, and electrolytes. This is also a good baseline if anything ever happens or if there is an underlying unknown disease.1. Is your pet over the age of 5?* Yes No a. Are you interested in a SENIOR PROFILE that tests for all the above today? ($120)* 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 dog has any pre-existing conditions?* Yes No 4. We STRONGLY recommend at least a Chemistry panel and CBC that checks for liver and kidney function (most medications are filtered through these organs), dehydration, and total 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? ($120)* Yes No HEARTWORMS: These are parasites that are given to indoor & outdoor dogs by mosquitoes. All dogs should be on prevention every month, year round. When a mosquito with heartworm disease bites a dog it transmits larva which grow into small worms called microfilaria over the course of 2 months. Heartworm prevention can only kill the worms, not the larva. It only takes ONE infected mosquito to transmit this disease.1. Is your pet on monthly Heartworm Prevention?* Yes No a. What kind?*b. Do you need another year's supply?* Yes No I) Different amt wanted*2. If your dog is more than 6 months old and never had a test or has not been on prevention OR if it has been more > 1 year, a heartworm test is required to receive prevention (a recommendation of the American Heartworm Association). Does your dog need a HEARTWORM TEST TODAY? ($48)* Yes No INTESTINAL WORMS: Dogs may become infected with hookworms, roundworms, whipworms, & tapeworms. Both hookworms & roundworms are contagious to humans, especially children or the immunocompromised, causing blindness, & skin infections. Monthly heartworm preventions (excluding Revolution in dogs) will kill hooks, rounds & whips monthly, but will not completely rid the infection. Please submit a fecal sample yearly to assess for these parasites $30OPTIONAL VACCINES: These are vaccines that are dependent on your pet's lifestyle and vaccine history.1. KENNEL COUGH Infectious respiratory virus which suppresses the immune system and can cause a pneumonia May be caused by bordetella bronciceptica, adenovirus or parainfluenza virus. We recommend and require all boarding or groomed dogs to be vaccinated every 6 months with Intra-trac III vaccine that covers all the above to hopefully prevent the infection or at least decrease the symptoms.a. Does your dog get boarded or groomed?* Yes No b. Do you live in a suburb or walk your dog in areas that they may be exposed to other dogs?* Yes No c. Does your dog need a kennel cough vaccine today ($25)* Yes No 2. CANINE INFLUENZA VACCINE A new flu virus of dogs that can potentially be fatal. It is required for most boarding facilities and some groomers. We have seen several confirmed cases this year. This vaccine also needs a booster in 3 weeks if you pet has never had one.a. Has your dog been vaccinated against Canine Influenza in the past?* Yes No b. Do you want your dog vaccinated today? ($45)* Yes No 3. LEPTOSPIROSIS A bacterial infection spread by raccoon, fox and squirrel urine that causes kidney and liver failure and is contagious to people.a. If your dog was not vaccinated in the past, would you like him/her to be today? ($30)* Yes No (Cost is $30 and will need boostered in 3 weeks)4. LYME DISEASE VACCINE A very common vaccination for the mid-west to prevent a potentially deadly disease spread by deer ticks. We have seen several positives here in Holt – Highly recommended if you have tall grass and/or trees. Lymes disease can go without symptoms for several years and can be difficult to cure. Lymes can cause kidney failure, joint pain and inflammation, lameness, fevers, generalized lethargy.a. Would you like to test your dog to see if they have been exposed to lymes disease? ($48)* Yes No (Recommended if you have seen an attached tick > 4 weeks ago)b. Would you like to vaccinate your pet against lymes disease? ($45)* Yes No FLEA AND TICK PREVENTION: There are multiple kinds of prevention that depends on your pet and your environment. Please ask our staff which would be right for you.1. Is your pet on flea/tick prevention?* Yes No a. What kind?*b. Do you need another year's supply?* Yes No Different amt needed*2. Do you have any questions about prevention?* Yes No a. Please explain:*IS THERE ANY OTHER QUESTIONS OR CONCERNS WITH YOUR PET TODAY?
