Client Name *

First

Last

Pet's Name *

Date *

Primary Phone *

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Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Wellness testing and preventative health care allow us to establish base line values and identify existing health problems that can go unnoticed in their earlier stages. By answering the following questions about your furry family member and allowing us to perform annual blood/urine testing as well as other diagnostics, you can assist us in detecting the onset of diseases and conditions early.

**I authorize my pet to have annual bloodwork performed: (Senior panel for pets 7 years and over is $169 and includes a heartworm test for dogs and cats.)
Canine comprehensive panel is $109 and includes a heartworm test.
Feline comprehensive panel is $97

Bloodwork *

Yes
No

I authorize my pet to have an intestinal parasite screening $35.00 (fecal test): *

Yes
No

I authorize my pet to have a heartworm test $37.00 (Canine only): *

Yes
No

I would like my pet to have a nail trim ($25.00 canine and $18.00 feline) *

Yes
No

I would like my pet to have an anal gland expression (canine only) $30.00 *

Yes
No

Risk factors (FOR CANINES ONLY): These can help us evaluate your pet’s potential risk for leptospirosis, canine influenza, lyme and other tick-borne diseases.

(if you check yes to any of the following, the veterinary technicians will go over the recommended vaccines with you)

• Has contact with other pets*

Yes
No

• Has the opportunity to drink from ponds, puddles, or standing water

Yes
No

• Has access to livestock or wildlife+

Yes
No

• Goes to the dog park, boarding facility or grooming*

Yes
No

• Travels outside of the State of FL**

Yes
No

• Has access/goes in heavily wooded areas**

Yes
No

Risk factors (FOR FELINES ONLY): These can help us evaluate your pet’s potential risk for feline leukemia or FIV.

• Is strictly indoors only

Yes
No

• Is mainly indoors only but has access to screened in lanai

Yes
No

• Is both indoors and outdoors with no restrictions

Yes
No

• Is outdoors only

Yes
No

Preventions and medications:

• Is your pet on monthly flea/heartworm/tick prevention?

Yes
No

Brand:

Date last given:

Signature *

Clear Signature

Date *

Wellness Exam Form

Wellness Exam Form

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Online Pharmacy

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Contact

Hours

We proudly serve the pets of San Antonio, FL and the Surrounding Areas:

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