Annual Exam Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Pet's Name(Required)

Who should we contact to make medical decisions today?

Owner (Named Above)

Someone Else (Named Below)

Reason for visit:

(check all that apply)

Annual Physical

Heartworm/Tick test (dogs)

Fecal/intestinal parasite screen

Deworming treatment

Annual physical - unsure of other services that are due. Would like to discuss with veterinarian.

Dog Vaccines

DHPP

Lepto

Rabies

Lyme

Bordetella

Unsure, would like to discuss recommendations with veterinarian

Feline Vaccines

FVRCP/Distemper

Rabies

Feline Leukemia (FeLV)

Unsure, would like to discuss recommendations with veterinarian

Other procedures:

(All procedures at additional cost)

Anal glands

Nail trim

Ear cleaning

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 (explain below)

Car Sickness

Behavioral Problem

Other (explain below)

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

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

Yes

How much do you feed?

Free fed (food is offered always/whenever hungry)

Measured amount (specify how much and how often below)

What brand of food do you feed your pet?

Do you have insurance for your pet?

Yes

Do you give your pet heartworm or flea/tick preventative?

Yes

Do you wish to take home flea/tick/heartworm prevention today?

Yes

Unsure, speak with a veterinarian about recommendations for my pet

What percentage of time does your pet spend outside?

Have you seen any fleas or ticks on your pet?

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

Is your pet on any medications?

Yes

Was your pet last seen by a veterinarian at True Companion Veterinary Care?

Yes

Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.(Required)

I understand that financial responsibilities for services are rendered at the time of discharge.

I have read and understand.

CPR PERMISSION(Required)

I understand True Companion Veterinary Care, PLLC (TCVC) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of TCVC, PLLC will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400. I understand that there is no guarantee of successful resuscitation.

Yes, please perform CPR on my pet.

No, do not perform CPR on my pet.

I give True Companion Veterinary Care authorization to treat as discussed above.(Required)

I have read and agree.

Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days?

Yes

Have you or anyone in your house experienced the following symptoms in the past 14 days?

Cough

Shortness of breath

Fever

Sore throat

Chills

Muscle pain

Headache

New loss of taste or smell

Who experienced these symptoms?

Self

Someone else in the house

No symptoms

If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment*

If Curbside care is elected: 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 outside the building and support them through the exam, any services required, and then bring them back to your vehicle, when your pet is ready to go home. We strongly recommend you head home and a veterinarian or nurse will call you to discuss your pet’s exam and discuss recommended treatments, preventative measures and give an estimated discharge time.

I have read and understand.

Communicating during the appointment:(Required)

Day Admission appointments: A day admission appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that your pet will be worked into the schedule between scheduled patient appointments for this service. Your pet will be cared for and housed in a kennel until they are able to be seen and 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.

Social Media/Photo Permission

Do we have your permission to post photos of your pet online? Your pets' picture or video may be taken while they are with us and used for True Companion Veterinary Care advertisement (www.truecompanionvetcare.com) or other social media purposes (Facebook, SnapChat, Instagram, etc.). Please indicate if you authorize for their pictures/videos to be posted or used. * If you do not authorize for your pet’s picture to be included in our marketing materials/venues, we may still use a picture of your pet in our patient records for our internal identification only*

Yes

PHOTO ID REQUIRED FOR PAYMENTS(Required)

Photo ID required for all credit card, debit card, Care Credit and Scratchpay transactions. The photo ID must match the name on the card. All credit card, debit card, Care Credit and Scratchpay holders must be physically present to run the card and sign the transaction in person.

I have read and understand.

Cancellation Policy(Required)

I understand that appointment cancellations less than 24 hours before appointment and/or no shows will incur a $65.00 cancellation fee.

Please type your initials.(Required)

Date

MM slash DD slash YYYY

Signature

This field is for validation purposes and should be left unchanged.

832-930-7717