Please fill out this form the evening before your pets visit. If worms were found at a previous visit or you did not bring a fecal to a previous visit please bring a fresh fecal sample to this appointment. If there is any diarrhea, vomiting or coughing please keep your pet in the car when you arrive and call 704-487-7595 to let us know you have arrived.

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Name *

First

Last

Cell Number *

Pet's Name *

Name and Cell Number of person bringing pet to appointment *

I understand that I am financially responsible for decisions made by the person that brings my pet to the appointment.

Address *

We want to be sure your address is current on file.

Change in appetite?

• No
• Increase
• Decrease

Vomiting?

• Yes
• No

If vomiting- How much? How often? Appearance(whole food, blood)

What do you feed your pet? How much and how often? *

Also include treats and any human food your pet is given.

Excessive scratching or itching?

• Yes
• No

Any scooting, chewing, or licking at bottom?

Lumps or Bumps?

Decreased energy levels?

• Yes
• No

Coughing, sneezing or difficulty breathing?

• Yes
• No

Describe if yes for coughing, sneezing or difficulty breathing?

Any change in bowel movements? If so please describe(consistency or frequency)

Change in drinking?

• No change
• Increase
• Decrease

Change in urination?

• No change
• Increase
• Decrease

Do you board your pet, take to day care or grooming?

• Yes
• No

Does your dog travel out of state? *

• Yes
• No

When did you give the most recent preventative (flea, heartworm, deworming)? *

Please list the name and date each product was given.

Please list all other medications and supplements your pet currently receives and their frequency. *

Please note any concerns you have that are not on this list so we can address them as well.

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