"*" indicates required fieldsStep 1 of 911%Date* MM slash DD slash YYYY Your Name* First Last Your Pet's Name:*Pet's age*Pet's Sex:* Male FemaleSpecies:*Reason for the exam:*Is your pet allergic to any medications that you're aware of (please indicate the name of the medication if applicable)?:*Currently taking medications? Dosages?:Heartworm PreventionIs your pet on heartworm prevention?* Yes NoPlease indicate the brand and when it was last given:*Canines: Date of last heartworm test: MM slash DD slash YYYY Feline FeLV/FIV TestFelines: Has your pet had a FeLV/FIV test? Yes NoFlea and Tick PreventionIs your pet using flea and tick prevention?* Yes NoPlease indicate the brand and when it was last applied*ObservationsCoughing or sneezing?* Yes NoVomiting or diarrhea?* Yes NoChange in appetite or thirst?* Yes NoObserved/felt lumps or bumps?* Yes NoObserved scratching or licking?* Yes NoSoreness or stiffness after resting or exercise?* Yes NoChange in outside or litterbox habits?* Yes NoObserved/felt change in weight?* Yes NoBehavior changes?* Yes NoDietWhat food are you feeding your pet?*Frequency of feeding per day (please be specific)* x1 a day x2 a day x3 a dayServices RequestedPlease specify requested services: Vaccines Lab Work Nail Trim Anal Glands Microchip None of the aboveAnything else you'd like us to know?Consent* I am providing my consent to the outlined services.By providing my name I give Queenstown Veterinary Hospital my authorization for all noted Drop-Off Exam requests.Phone number where I can be reached:*CAPTCHAΔ
