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!

Canine Wellness Check In Form

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 if you need to update your mailing address)
Street Address
City
,
State / Province
Zip / Postal Code
Main Contact Phone Number
Phone TypePhone 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:

Seresto - 8 month collar
Frontline Gold - Monthly liquid spot-on
Nexgard / Credelio - Monthly Oral
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 Chewabl
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



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