Annual exam

Name(Required)
Who should we contact to make medical decisions today?
Reason for visit:
(check all that apply)
Dog Vaccines
Feline Vaccines
Other procedures:
(All procedures at additional cost)
Are there any concerns for the following: (check all that apply)
Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?
How much do you feed?
Do you have insurance for your pet?
Do you give your pet heartworm or flea/tick preventative?
Do you wish to take home flea/tick/heartworm prevention today?
Have you seen any fleas or ticks on your pet?
Do you have other pets?
Does your pet come into contact with other dogs?
Please check all that apply
Is your pet on any medications?
Was your pet last seen by a veterinarian at Your Veterinary Practice?
Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.(Required)
CPR PERMISSION(Required)
I understand Your Veterinary Practice- requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of Your Veterinary Practice will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400. I understand that there is no guarantee of successful resuscitation. 
I give Your Veterinary Practice authorization to treat as discussed above.(Required)
Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days?
Have you or anyone in your house experienced the following symptoms in the past 14 days?
Who experienced these symptoms?
If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment*
Communicating during the appointment:(Required)
Social Media/Photo Permission
Do we have your permission to post photos of your pet online? Your pets' picture or video may be taken while they are with us and used for Your Veterinary Practice advertisement (www.truecompanionvetcare.com) or other social media purposes (Facebook, SnapChat, Instagram, etc.). Please indicate if you authorize for their pictures/videos to be posted or used. * If you do not authorize for your pet’s picture to be included in our marketing materials/venues, we may still use a picture of your pet in our patient records for our internal identification only*
Cancellation Policy(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.