Annual wellness Appointment Form

Centennial Animal Hospital Annual Wellness Appointment Form

Thank you for entrusting your pet’s care to us! The following information will be used to help our veterinary team accurately complete your pet’s medical history for their visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.

Check-in for all visits will occur over the phone, so please provide the information below even if you intend to attend your pet’s appointment. Thank you!

"*" indicates required fields

Date of Appointment*

Time of Appointment*

:

Name*

First Last

Email*

Phone*

Pet's Name*

Species*

Dog

Cat

Other

If other, please specify*

Who should we contact to make medical decisions today?*

Myself

Someone else

Name*

First Last

Phone*

Should we call as you wait in your vehicle for a curbside visit, or would you prefer to have ONE adult to be present in the exam room?*

In-person visit

Call

Reason for visit (check all that apply):*

Annual physical and vaccines that are due

Heartworm/tick test (dogs only)

Fecal/intestinal parasite screen

Annual physical - unsure of other services that are due. Would like to discuss the recommendations.

Dog Vaccines*

Rabies (required by law on all pets 16 weeks an older)

Distemper, parvo, parainfluenza (core vaccine)

Leptospirosis (core vaccine)

Bordetella (core vaccine, required for surgery, boarding & grooming)

Influzenza Bivalent (H3N2, H3N8) (required at some boarding)

Rattlesnake vaccine (lifestyle based on risk of hiking trails and backyards)

Unsure, would like to discuss recommendations

Cat Vaccines*

Rabies (required by law on all pets 16 weeks an older)

FVRCP/distemper (core vaccine)

Feline Leukemia (FeLV) (lifestyle if outdoor)

Unsure, would like to discuss recommendations

Other procedures (all procedures at additional cost):*

Heartworm test (dogs yearly)

Anal gland expression

Nail trim

Ear cleaning

Sanitary cleaning

None

Have you noticed any issues/problems with your pet? Are there any concerns for the following (check all that apply):*

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?*

If other, please specify*

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?*

Yes

No

If yes, please explain*

What brand and type of food do you feed your pet?*

How much do you feed?*

Free fed (food is offered always/whenever hungry)

Measured amount (specify how much and how often below)

How much and how often do you feed your pet?*

Do you have insurance for your pet?*

Yes

No

Do you give your dog heartworm prevention?*

Yes

No

Please select the brand of heartworm prevention you give your dog*

If yes, when was the last dose given?*

Do you need to take home heartworm prevention today?*

Yes

No

For in-clinic purchase of 6 months of Interceptor Plus, get one dose free; with the purchase of 12 months, receive a $15 manufacture mail in rebate.

How would you like to purchase your heartworm prevention?*

In house - 6 month supply

In house - 12 month supply

Online pharmacy

Written prescription (can be mailed to the online or local pharmacy of your choice)

Do you already have an account with our online pharmacy, Myvetstore?*

Yes

No

Please enter the email that we can set up an account for you*

Do you give your pet flea and tick prevention?*

Yes

No

Please select the brand of flea and tick prevention you give your pet*

If yes, when was the last dose given?*

Do you need to take home flea/tick prevention today?*

Yes

No

For in-clinic purchase of Nexgard: 3 months get a free dose; 6 months get a $15 manufacture mail-in rebate; 12 months get a $35 manufacture mail-in rebate

How would you like to purchase your flea/tick prevention?*

In house - 6 month supply

In house - 12 month supply

Online pharmacy

Written prescription (can be mailed to the online or local pharmacy of your choice)

Do you already have an account with our online pharmacy, Myvetstore?*

Yes

No

Please enter the email that we can set up an account for you*

What percentage of time does your pet spend outside?*

Have you seen any fleas or ticks on your pet?*

Yes

No

Does your pet travel out of state?*

Yes

No

Do you have other pets?*

Yes

No

Does your pet come into contact with other dogs? Please check all that apply*

None

Boarding

Grooming

Dog parks

Other

If other, please specify*

Is your pet on any medications?*

Yes

No

If yes, please list medication name, dosage, and frequency*

Was your pet last seen by a veterinarian at Centennial Animal Hospital?*

Yes

No

Name of Previous Veterinarian*

Many of our patients enjoy treats while visiting our office, but if your pet has an allergy, please let us know or bring approved treats.

Can your pet have treats (low fat I/D kibbles, or cheese)?*

Yes

No

I understand that financial responsibilities for services are rendered at the time of service, we are happy to provide estimate for additional services on request.*

I have read and understand

I give Centennial Animal Hospital authorization to treat as discussed above.*

I have read and understand

In-person visit: Please call or text our team when you arrive to check in. When the doctor is ready to examine your pet, a team member will escort you into the exam room. We ask that you remain seated during the exam and allow a trained patient handler to provide physical support to your pet. Once the exam has been performed and a plan has been discussed and approved with the veterinarian, we may ask that you return to your vehicle while the doctor and technicians complete any diagnostic services discussed (such as bloodwork, x-rays, or other therapies). As with curbside visits, we will call or send a secure link for payment after the visit is complete and bring your pet back to you. This will allow for proper cleaning time between patients to keep all our patients, clients, and team members as healthy as possible.*

I have read and understand

Critter concierge: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from the car and support them through the exam, any services required, and then bring them back to your vehicle at the end of the appointment. Unless otherwise noted, your pet’s care will be performed while you remain in the parking lot. A veterinarian or technician will call you in your vehicle to discuss your pet’s exam and discuss recommended treatments or preventative measures.*

I have read and understand

Drop off appointments: A drop off appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that there is an additional charge for this service as your pet will be cared for and housed in a kennel until they are able to be picked up. If you need to leave your pet for their appointment, please inform the team member who collects your pet from the car and the receptionist who answers the phone when you first arrive.*

I have read and understand

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above mentioned pet.*

I certify

Signature*

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We treat your pets like the valued family members they are.

Address

6870 Centennial Blvd.
Colorado Springs, CO 80919
Click here for directions.

Hours

Mon – Fri: 8:00 am – 6:00 pm
Sat: 8:00 am – 12:00 pm
Sun: Closed

Contact

Phone: 719-528-1693
Fax: 719-528-1694
Email: centennialpets@gmail.com

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