Wellness Appointment Drop Off Form

Wellness Appointment Drop Off

Client's Name(Required)

First

Last

Pet's Name(Required)

Phone number(s) where you can be reached today:(Required)

*If any of your contact information has changed, please notify us*

To Better Assist Us in Treating Your Pet, Please Answer the Following Questions. Thank You!

Reason for visit:(Required)

Routine Wellness

Vaccines

Other

If other, please specify:

Please list any additional treatments/services you wish your pet to receive today:

Nail trim $30

Express anal glands $48

Ear cleaning $54

Sanitary shave $62

Please list any medications and supplements your pet is currently taking (including over the counter medications):(Required)

Please list your pet’s current diet (brand, amount & frequency):(Required)

Any medical history or chronic conditions? Please list if applicable.(Required)

Any history of vaccine reactions? If so, what kind of reaction? Your pet may require premedication.(Required)

Is your pet currently on heartworm prevention?(Required)

Yes

What type of heartworm preventative is your pet on?

What was the date the last dose of heartworm preventative was given?

Has your pet missed any heartworm preventative doses?

Is your pet on flea/tick preventative?(Required)

Yes

What type of flea/tick preventative is your pet on?

What was the date the last dose of flea/tick preventative was given?

Has your pet missed any flea/tick preventative doses?

All pets admitted will be given any vaccinations that are due, unless medically contraindicated. All pets admitted will also be treated for any external or intestinal parasites found at the owner’s expense. Please alert us if any vaccine reaction history.

Preventative blood work is important to establish a baseline for your pet’s health, to monitor trends, and to catch disease early. Please choose from the following wellness panels that we offer:(Required)

Adult Early Detection blood panel (includes CBC to evaluate blood cells, chemistry to evaluate basic organ function, heartworm and tick testing, and fecal) $195.00

Senior Early Detection blood panel (includes all the above plus thyroid check and urinalysis) $290.00- recommended for patients 7 years and older

I decline preventative diagnostics

Heartworm prevention- select one option(Required)

6-month injection – 2-8lbs $47.00

6-month injection – 8.1-25lbs $50.00

6-month injection – 25.1-50lbs $63.00

6-month injection – 50.1-100lbs $95.00

6-month injection – >100lbs $149.00

12-month injection – 2-8lbs $95.00

12-month injection – 8.1-25lbs $98.00

12-month injection – 25.1-50lbs $125.00

12-month injection – 50.1-100lbs $170.00

12-month injection – >100lbs $230.00

Interceptor plus (heartworm and intestinal parasites-1 month up to 12 month)- 1 tab monthly; $8-13/tab

I decline heartworm, flea, and tick prevention.

_____ # of months/tablets requested today

Flea and Tick Prevention-select one option(Required)

Simparica (1 month up to 12month)- 1 tab monthly; $22-24/tab

I decline heartworm, flea, and tick prevention.

_____ # of months/tablets requested today

Heartworm and Flea/Tick prevention combined (chosen instead of items above)(Required)

Simparica Trio (1 month up to 12 month)- 1 tab monthly; box of 6 ~$145-165

I decline heartworm, flea, and tick prevention.

_____ # of months/tablets requested today

Note: If preventative blood work is declined, an in-house heartworm test is required before starting new preventatives or if doses have been missed. $89 Please initial that you have read and understand the above statement. *

I understand that if my pet is found to have a medical condition requiring further treatment, the staff of Vida Veterinary Care will make every effort to contact me with recommendations and treatment plans.(Required)

I agree

If we cannot reach you, do you wish for us to proceed with these treatments?(Required)

Yes

Please elect CPR or DNR status in unlikely case of cardiac or respiratory arrest.(Required)

CPR

DNR

I, the undersigned, certify that I am the owner or duly authorized agent for the owner of the Patient, described above and accept full financial responsibility. I authorize the veterinarians, and agents of Vida Veterinary Care to perform the services listed above and understand that support staff will be utilized at the doctor’s discretion. I accept that full payment for services and products is expected at the time my pet is discharged. Please sign below to agree.

Owner/authorized agent first and last name

First

Last

CAPTCHA

Wellness Appointment Drop Off Form

Wellness Appointment Drop Off

To Better Assist Us in Treating Your Pet, Please Answer the Following Questions. Thank You!

To Better Assist Us in Treating Your Pet, Please Answer the Following Questions. Thank You!