Dog Annual Examination Report in Mercer, PA | Pet Set Go! Mobile Veterinary Services

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Name

First Last

Date

Dog Name

Age

Weight (lbs)

If your contact information has changed since your last visit, please proide new information

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email

Do you have pet insurance

If yes, please list name of provider

Please completed the following information about your dog’s health

Do you use a heartworm preventive?

If yes, list name and Date administered

Do you use a flea/tick preventive?

If yes, list name and Date administered

Have you seen fleas or ticks on your dog?

Do you have any other dogs or cats?

If yes, how many? Number of other Dogs and number of other cats

Are all dogs and cats currently vaccinated and on heartworm and flea preventive?

If no, please explain

Any other pets?

If yes, please explain (type of animal, how many, general health)

What best describes the amount of time your dog spends outdoors?

Check if your dog does any of the following

What brand of food do you feed your dog?

How much and how often?

Do you provide any dental care for your dog?

If yes, please explain

Have you noticed any lumps or bumps on your dog?

If yes, please explain

Have you noticed any skin/coat problems on your dog?

If yes, please explain

Check if you have noticed any of the following:

Other

Does your dog have any behaviors you wish you could change?

If yes, please explain

Please list any health issues you would like to discuss with the veterinarian