Preventative Care Patient History | Companion Wicker Park

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Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.

Client Information

First Name*

Last Name*

Email*

Appointment Date/Time*

What phone number can we call you at while your pet is here?*

Pet Information

Pet Name*

Pet Age*

Species*

Canine (Dog)

Feline (Cat)

Other

If other, please specify*

Breed*

Microchipping is permanent identification for your pet. Having your pet microchipped is an excellent way to locate your pet should it become lost.*

My pet is already microchipped

I’m interested in learning more

I’m not interested in microchipping

Are there any concerns for the doctor to consider this visit?*

Does your pet have a good appetite?*

Yes

If no, please explain*

Is your pet drinking and urinating normally?*

Yes

If no, please explain*

Is your pet*

Sneezing

Coughing

Itching

N/A

Please explain more*

Is your pet having any vomiting or diarrhea?*

Yes

If yes, please explain*

We recommend annual fecal testing for intestinal parasites (Intestinal Parasite Exam)*

Bringing small sample to appointment

Please send home with a prepaid collection container to drop off sample at my convenience

I would like to learn more about regular fecal testing

My pet eats (choose all that apply)*

Wet food only

Dry food only

Wet and Dry Mixture

People Food

Raw Diet

Home Cooked Diet

Other

If other, please explain*

Brand of food?*

If prescription diet, what formulation?*

How often is your fed?*

How much is your pet fed?*

In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides, etc)*

Has your pet's diet changed in the last 6 months?*

Yes

I am not sure

If yes, please specify*

Do you brush your pet's teeth?*

Yes

How often?*

Current medications / supplements (name, dose, frequency given)*

Do you need any refills?*

Yes

To help keep healthy, year round heartworm prevention is needed due to the variable nature of mosquito seasons. Mosquitoes can be known to live in your basement/attic and in the sewer system all winter. In addition, heartworm preventatives once monthly help prevent several intestinal parasite infections. We recommend Interceptor Plus once monthly on a year round basis.

Heartworm Prevention refill?*

I want to discuss Heartworm Disease Preventative options with a vet nurse

I have prevention at home

My pet does need to be protected against Heartworm Disease

Pets we consider at higher risk of ticks include dogs that go outside. This area has a high incidence of Lyme Disease. Tick-borne diseases such as Lyme Disease are easier to prevent than treat. If your pet has possible exposure, then vaccination for Lyme Disease and applying/giving YEAR ROUND flea/tick preventative is needed. Pets that are in contact with other dogs, such as dog parks or daycare need year round flea/tick prevention.

Flea Prevention Refill?*

I want to discuss flea preventative options with a vet nurse

I have prevention at home

My pet does need to be protected against fleas

Is there anything else you would like to discuss today?

Appointment Procedures

We are happy to announce that our doors are now open to human clients! We need your help to make this transition as safe as possible for everyone. Car side appointments are still available! If you prefer this option, please let us know and a team member will come out to you & your pet.

I understand that payment is due, in full, at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone*

Please initial

Signature*

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