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*Reset signature Signature locked. Reset to sign again What brand of pet food does your pet eat and is it "grain free"?*Has your pet eaten anything in the past 12 hours? (including treats)* Yes No Please list ALL medications your pet is currently taking AND the doseMedicationDosage What type/brand of heartworm preventative are you using? Heartgard Sentinel Simparica Trio Last GivenWhat type/brand of flea/tick preventative are you using?* Frontline Nexgard Bravecto Last 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?* Yes No If 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*Reset signature Signature locked. Reset to sign again
