Canine Annual Wellness - VMS Veterinary Medicine and Surgery

It's Time For Your Puppy or Dog's Yearly Exam

Canine Annual Wellness Form

First Name

Last Name

Phone

Pet Name

Pet Breed

Date of Birth

Sex

Spayed / Neutered

What type of food do you feed your pet?

How much and how often is your pet fed?

What type of heartworm prevention and flea control are you giving your pet?

When was the last dose of heartworm prevention and flea control given?

Would you like a refill of heartworm prevention or flea control today?

Any coughing, sneezing, vomiting, or diarrhea?

Is your pet on any medications?

Any problems that you know of at this time?

Is your pet exposed to any unfiltered water that it may drink out of, such as ponds?

Is your pet in an environment where snakes live? If yes, do you want the snake bite vaccine at an additional charge?

Has your pet ever had a reaction to vaccines?

Is your pet microchipped?

Do you have an insurance policy for your pet?

Thank you for completing our Canine Annual Wellness Form. Please press the submit button to send this form to our main office.