Preventive Care Survey For Dogs

Preventive Care Survey For Dog

Please provide your details below and we will get back to you shortly.

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Dog’s Name *

Your Name *

First

Last

Email *

Phone Number *

Is your dog microchipped? *

• Yes
• No
• Unsure

Please tell us about your dog’s diet *

Please tell us about any treats, dental chews, and human food your dog receives.

Your us your

Your dog’s body condition is

• Overweight
• Ideal
• Underweight
• Unsure

Which Heartworm prevention is your dog receiving? *

• Interceptor Plus
• Heartgard Plus
• Proheart6
• None
• Other

When was your dog’s last dose given? *

Which flea & tick prevention is your dog receiving *

• Bravecto
• Nexgard
• Credelio
• None

When was your dog’s last dose given? *

Please tell us about any other prescription, OTC medications, &/or supplements your pet is taking, including current dose and frequency.

Please check any of the following that apply: *

• My dog lives with other animals
• My dog lives with children
• My dog visits parks
• My dog goes to grooming/boarding facilities

If your dog is having any mobility or comfort issues, please describe them here.

If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.

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