Drop Off Exam | Western Shore Veterinary Hospital

Date(Required)

Your Name(Required)

First Last

Your Pet's Name:(Required)

Pet's age:(Required)

Pet's Sex:(Required)

Species:(Required)

Reason for the exam:(Required)

Is your pet allergic to any medications that you're aware of (please indicate the name of the medication if applicable)?:(Required)

Currently taking medications? Dosages?:

Heartworm Prevention

Is your pet on heartworm prevention?:

Yes

No

If yes please indicate the brand and when it was last given:

Canines: Date of last heartworm test:

Feline FeLV/FIV Test

Felines: Has your pet had a FeLV/FIV test?:

Yes

No

Flea and Tick Prevention

Is your pet using flea and tick prevention?(Required)

Yes

No

If yes please indicate the brand and when it was last applied:

Diet

What food are you feeding your pet?:(Required)

Frequency of feeding per day (please be specific):(Required)

x1 a day

x2 a day

x3 a day

Services Requested

Please specify requested services:

Vaccines

Lab Work

Nail Trim

Anal Glands

Microchip

None of the above

Anything else you'd like us to know? :

By providing my name I give Queenstown Veterinary Hospital my authorization for all noted Drop-Off Exam requests.(Required)

Phone number where I can be reached:(Required)

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Heartworm Prevention

Feline FeLV/FIV Test

Flea and Tick Prevention

Observations

Diet

Services Requested