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Wellness Appointment Form

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Please review the following to ensure a smooth and timely appointment:

A pre-visit questionnaire is required for all appointments, please complete the
questionnaire below in advance to prevent a delay to your appointment check-in.
If your pet requires pre-visit sedative medication, please give at the appropriate time as
directed by your veterinarian. If you need a refill or have forgotten to administer your pet’s
medication please call us ASAP at 630-858-3530. Arriving without administering the
required medication will result in rescheduling.
Upon arrival please come into the lobby with your pet safely secured. Cats must be in a
carrier and dogs must be leashed or in a crate.

Name*

First

Last

Phone*

Email*

Pet's Name*

Appointment Date and Time*

What kind of food are you feeding and how much and frequency?*

What medications/supplements is your pet on? Do you need any refills?*

Is your pet on preventatives? (ie: Heartgard/Nexgard or Simparica Trio) Brand/last given?*

Dog Lifestyle: Are there any changes since our last visit? Outdoors, Dog Parks, Daycare, Grooming, Training Classes, Hunting, Camping, etc?*

Cat Lifestyle: Is your cat Cat indoor only?*

Is there any coughing, sneezing, vomiting, diarrhea?*

Has your pet had a previous vaccine reaction?*

Any concerns for your pets visit today? Please try to be specific with details (i.e. the length of time a problem has been occurring, where a mass is located/how long it has been present, which leg is affected by limping, etc.)*

Signature*

Date*

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