Canine Wellness Check In Form

Mazomanie Animal Hospital, LLC

704 Emily Rd
Mazomanie, WI 53560

(608)795-4242

www.mazoanimalhospital.com

Canine Wellness Check In Form

Thank you for scheduling a Wellness Exam Visit with your pet! We look forward to your visit!

Please fill out the form below to help us best serve you and your pet during their visit.

Thank you for your time!

Email (This should be the main email you would like us to use for your account) (required)

Dog's Name (required)

Owner's Name (That account is under in our system) (required)

Who will be bringing your dog to their appointment? (required)

What is the best contact number for that person? (required)

Current Mailing Address (Please fill in ONLY if you need to update your mailing address)
Street Address

City ,	State / Province	Zip / Postal Code

Main Contact Phone Number
Phone Type	Phone Number

Has your dog shown any of the following signs or symptoms? If no, leave blank. If yes, please explain.

Coughing, gagging, or wheezing?

Vomiting, Diarrhea or Scooting on rear end?

Red gums, offensive breath, excessive drooling, or sensitivity while chewing?

Lameness or difficulty when getting up?

Lethargy, listlessness or anxiety (hiding or uncontrollable shaking)?

Unusual body odors, itching, scratching, poor hair coat, hair loss, skin problems or ear odor/head shaking?

Lumps or bumps?

Has your dog shown a significant change in any of the following? If no, leave blank. If yes, please explain.

Change in appetite or increase in drinking?

Weight gain or loss?

Change in behavior, training or behavioral issues?

Difficulty in Hearing or with Vision?

ENVIRONMENTAL EXPOSURES AND TESTING

Is your dog primarily:

Indoor Dog
Outdoor Dog
50/50
Other

Tick Exposure Level:

High
Moderate
Very Low

Mosquito Exposure Level:

High
Moderate
Very Low

Does your dog eat prey, their own stool, or stool of other animals?

Yes
Rarely
No

We recommend YEARLY testing for the following diseases:

- Heartworm Disease: Contracted by a single mosquito bite, fatal in not detected, symptoms take 1-2 years to develop

- Lyme Disease: Contracted by a Deer Tick bite. Most common infectious disease we see in dogs! Most cases can be treated with antibiotics, rarely it can lead to severe and fatal complications

- Anaplasma: Similar in many ways to Lyme Disease, except symptoms can be very vague, chronic, or recurrent

Routine Screening Tests- I would like:

Heartworm /Lyme/ Anaplasma test
I decline screening at this time
I am unsure and would like to discuss further

Flea / Tick Prevention:

Simparica TRIO [COMBINATION Flea/Tick AND Heartworm/Parasite Control] - Monthly Chew
Nexgard - Monthly Chew
Seresto - 8 month collar
Frontline Gold - Monthly liquid spot-on
Other (Please make a note in the box below)
I am unsure and would like to discuss further
I do not need any prevention dispensed today

Heartworm / Intestinal Parasite Prevention

12 month supply - Monthly Chewable
Seasons worth - Monthly Chewable
12 month supply - Simparica TRIO [COMBINATION Flea/Tick AND Heartworm/Parasite Control]
6 month supply - Simparica TRIO [COMINATION Flea/Tick AND Heartworm/Parasite Control]
Other (Please make a note in the box below)
I am unsure and would like to discuss
I do not need any prevention dispensed today

Please enter products or prescriptions you would like to pick up today (Other than what is selected above)

OTHER

Do you brush your dogs teeth or give dental treats? If yes, please explain.

What food(s) does your dog currently eat?

What medications, including supplements, does your dog currently take?

Would you like your dog's nails trimmed today? (There is a fee for this)

Yes
No

Do you have any other questions or comments about your dog today?

Senior Screening / Preventative Wellness Bloodwork Screening

When your pet is in for it's Annual Wellness Exam we also offer the opportunity to have us perform some basic lab screening tests at a significant discount to ensure that your pets organs and metabolic functions are all working well.
These tests are even more important if your pet is:

- Over 7 years old
- Will need general anesthesia for a surgical or dental procedure in the coming months

- Has any chronic medical conditions
- Receives regular medications for a chronic problem

Are you interested in Preventative Wellness Screening for your dog today?

Yes
No
I am unsure and would like to discuss further

Verify the reCAPTCHA:

"We are about making animals healthier and happier."

Financial Options

Mazomanie Animal Hospital recognizes that medical care for your pet can be expensive and sometimes unexpected. To help our clients better cope financially with these situations, we offer Care Credit as a short term solution. You can apply through our office or online prior to arrival. If you apply online, please print your confirmation and bring it with you.

We also accept most credit cards, cash, and check payments.

"We are about making animals healthier and happier."

Financial Options

We also accept most credit cards, cash, and check payments.