Your Name*

Email Address*

Phone Number*

Pet Name*

Do you have any behavioral or health concerns you would like to discuss at this appointment?

Please list current food & amount feed*

Please list treat - types & amount *

Please list any medications (including flea/tick medication, supplements, etc) your dog is taking*

Do you need a refill of any of these medications?

Preferred pharmacy for your pet’s medications: Preferred pharmacy for your pet’s medications: Lodi Veterinary Care in hospital pharmacy Lodi Veterinary Care online pharmacy (free shipping) Other

If other, please list pharmacy

Are you interested in learning more about any of the following at your dog’s upcoming appointment? Are you interested in learning more about any of the following at your dog’s upcoming appointment? Age related changes (joint stiffness, vision or hearing changes, etc) Dental/oral care Boarding or Doggie Daycare New or changing lumps/bumps Wellness ultrasound screening Financing your pet’s healthcare Parasites (fleas, ticks, intestinal worms)

Would you like any additional services for your dog during this visit? Would you like any additional services for your dog during this visit? Nail trim Anal gland expression Ear cleaning