Annual Examination Drop-Off Form Patient's Name*Owner’s Name* First Last The vaccinations and/or diagnostics highlighted below are the vaccinations specifically recommended for your pet to keep them healthy and prevent diseases. A veterinary assistant will be happy to review the recommendations with you and answer any questions at the time you drop off your pet.Please initial next to the vaccinations and diagnostics that you authorize us to perform todayCaninePhysical ExamRabies vaccine (3 yr.)Distemper/Parvovirus vaccineLeptospirosis vaccineCanine Influenza vaccine (Bivalent)Bordetella/Kennel cough vaccineHeartworm & Tick-borne disease testFecal examinationFelinePhysical ExamRabies PureVax vaccine (1 yr.)Rabies vaccine (3 yr.)FRCCP (Feline Distemper) vaccineFeline Leukemia vaccineF.I.V./FeLV/HW TestFecal examination**We will attempt to perform the above procedures without sedation. However, in some cases it may be necessary to place your pet under a light sedation for their comfort. Your signature here indicates your acceptance of this procedure without additional prior notice. There is an additional charge for sedation.Owner Signature*Has your pet eaten anything in the last 12 hours (including treats)?*YesNoPlease list ALL medications your pet is currently taking AND the doseMedicationDosage What type/brand of heartworm preventative are you using?SentinelHeartgardTrifexisAdvantage MultiRevolutionLast GivenWhat type/brand of flea/tick preventative are you using?*FrontlineNexgardBravectoAdvantage MultiEffitixEffiproLast Given*Please note: If a flea or tick is seen while in our hospital, a product will be administered.Are there currently any problems or issues that you would like to have evaluated by a veterinarian today?*YesNoIf yes, please describe*Please provide a phone number where we can contact you in the event any questions should arise during your pet’s examination. We will also contact you at this number when your pet’s yearly is completed:*Owner Signature*
