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Canine History Intake Form
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Client Name
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Email
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Your answer
Phone Number
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Patient Name
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Patient Age
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Appointment Date
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What are you currently feeding your pet? Please list brand, how much and how often you are feeding each day.
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Your answer
Is your pet on any flea and tick preventative? If yes, please list the name of the product and when the last dose was given.
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Your answer
Is your pet on any heartworm preventatives? If yes, please list the name of the product and when the last dose was given.
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What types of dental care/maintenance do you do at home?
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What is your pet's tick exposure (travel history, exposure to wooded areas/tall grass)?
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Do you give your pet any medications or supplements? If yes, please list medication name, strength, and how often it is given.
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Is your pet spayed/neutered? If not, do you have plans to spay/neuter, breed, or are you unsure at this time?
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Do you have any concerns about your pet today? If yes, please explain.
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