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*

MM slash DD slash YYYY

Time of Appointment*

Hours

Minutes

AM/PM

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 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):*

Increase in appetite

Decrease in appetite

Increase in drinking

Decrease in drinking

Weight loss

Weight gain

Itching/scratching

Shaking head

Bad breath

Vomiting

Diarrhea

Urination issues

Excessive sleeping

Scooting

Difficulty rising

Skin masses

Car sickness

Behavioral problems

Other

None of the above

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

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

Do you give your dog heartworm prevention?*

Yes

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

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

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

Do you give your pet flea and tick prevention?*

Yes

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

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

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

Does your pet travel out of state?*

Yes

Do you have other pets?*

Yes

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

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

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

Yes

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

To allow ample time for all patients, CAH runs primarily by appointments. We request all clients to be on time for their scheduled appointments. If you are 15 minutes late to your appointment you may be asked to reschedule your appointment. If you have multiple concerns for your pet, please let us know when scheduling, otherwise you may need to schedule a follow up appointment to address additional concerns. Cancellation policy for appointments; please give us 24-hour notice so we can accommodate getting another patient in to be seen.*

I have read and understand.

You can expect most wellness and vaccine appointments to last about an hour from check in to check out. Sick and Urgent care appointments may require diagnostics which can take additional time. They can take (1-3 hours) from check in – check out.*

I have read and understand.

For your protection, and that of others, all pets should be properly restrained by a leash or carrier. If your pet requires special accommodation, please let us know when you arrive. We do ask that you still check in from the parking lot and we will bring you inside as soon as we have a room available.*

I have read and understand.

THE VETERINARIAN-CLIENT-PATIENT RELATIONSHIP (VCPR) is the basis for veterinary care and is critical to the health of your animal. This requires mutual trust and respect for us to provide the highest quality of care for your pets. We have a zero-tolerance policy for abusive, aggressive, bullying, or combative behavior. Should this behavior be directed toward any of our staff in person or on the phone we will terminate our VCPR with you immediately and you will need to find veterinary services elsewhere. If you have any questions or concerns about the treatments being recommended or the services provided, please let us know right away.*

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. If you send someone else in your place, they must be 18 years of age or older and you are authorizing them to act on your behalf. You are still financially responsible for all charges incurred for the care of this pet. I understand that payment is ALWAYS DUE IN FULL at time of service. We are happy to provide estimates for any recommended services, just let us know on arrival. A 50% deposit of the treatment plan may be required before treatments or hospitalization of your pet are rendered. I understand that any financial concerns should be discussed PRIOR to the examination and treatment consent. We accept cash, debit, or all credit cards. We also offer Care Credit or Scratch Pay.*

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

Ready to come see us?

Request an appointment online!

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