2025 Update - Has your phone number, address and/or email changed?

Yes

If yes, please enter that information here:

Client’s Name

Patient’s Name

Date

Contact Phone

E-mail Address

Please circle correct response

Inside

Always

Sometimes

Never

Outside

Always

Sometimes

Never

Does your pet ever board?

Yes

Is your pet used for hunting?

Yes

Is your pet used for breeding?

Yes

Have you noticed ticks?

Yes

Is your pet professionally groomed?

Yes

Any special situations we should be aware of prior to vaccinations?

Are you REGULAR with HEARTWORM PREVENTION?

Yes

WOULD YOU PREFER A 6 MONTH HW PREVENTIVE INJECTION? (CANINE ONLY)

Yes

Would you liked to have your pet MICROCHIPPED for PERMANENT ID

Yes

(Cost:$75.75) This also includes the first year of enrollment in a national database.

Would you like your pet to have Annual wellness bloodwork? ($139.86)

Our wellness bloodwork, A Complete Blood Cell Count (CBC) & Chemistry, looks for indicators of immune system function, bone marrow health, anemia, iron deficiencies, infections, stress, & diseases such as cancer, liver, kidney, & intestinal diseases, as well as assessing blood clotting ability through platelet count.

Do you want your pet to have an Influenza Vaccine? ($53.40)

Protect dogs against influenza vaccine H3N3 & H3N2. This vaccine helps reduce the severity of coughing, sneezing, nasal & ocular discharge, and dyspnea.

Vaccination Questionnaire

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Ridgetowne Animal Clinic