Mazomanie Animal Hospital

704 Emily Rd
Mazomanie, WI 53560


Feline 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!

Feline Wellness Check In Form Form

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

Cat's Name (required)

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

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

What is the best contact number for that person during the scheduled appointment time? (required)

Current Mailing Address (Please fill in ONLY if you need to update your mailing address)
Street Address
State / Province
Zip / Postal Code
Main Contact Phone Number
Phone TypePhone Number
Is this a cell phone that can accept text message reminders from us?


Has your cat 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 cat 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 or litter box use problems?

Difficulty in Hearing or with Vision?

Infectious Diseases:
Feline Leukemia (FeLV) and Feline Immunodeficiency Virus (FIV) These diseases are transmitted through bite wounds or other close contact with infected cats and can be fatal.
We suggest screening +/- vaccination for:
- Cats have had contact, or have been in fights with strays or other outdoor cats
- Sick cats or cats with chronic infections that don't resolve
- Any new cats (Before exposing to other household cats)
- ALL new kittens
Is your cat primarily:

Spends time Indoor and Outdoor
Multi-cat household

If your cat goes outside, what is it's exposure to other cats?

Very Often

If your cat goes outside, does it hunt and sometimes eat rodents or other animals?

Very Often

Routine FeLV/FIV test:

I am concerned and would like to have a test performed today
I would like to discuss the options further
I decline screening today

Please dispense today:

Revolution (Fleas, some ticks, ear mites, some intestinal parasites, heartworm) - Monthly spot-on
Seresto Collar (Fleas/Ticks) - 8 month collar
Frontline Gold Multidose (Fleas/Ticks) - Monthly Spot-on
Additional deworms for intestinal parasites
I am unsure what would be best and would like to discuss further

What food(s) does your cat currently eat?

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

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


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

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 cat today?

I am unsure and would like to discuss further

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